Authorization of Release of Health Information

Authorization of Release of Health Information
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
The following organizations/providers are hereby authorized to release, exchange and share my protected health information (PHI) with New Health Services, LLC, New Health Pain Treatment Centers and Englewood Surgery Centers:
Recipient/Healthcare Provider Name:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Fax Number

Area Code Phone Number
I authorize the following PHI to be released from my medical record (please mark all that apply):
I understand that the information in my health record may include information relating to sexually transmitted disease (STD), acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental services, and treatment of alcohol or drug abuse.
State and federal law protects the following information. If this information applies to you, please indicate if you would like this information released/obtained (include dates where appropriate):
Alcohol, Drug, or Substance Abuse Records

Yes No
HIV Testing and Results

Yes No
Behavioral Health

Yes No
Covering the period of healtcare from: Specific Dates:
From

Month Day Year
Date
To

Month Day Year
Date
Requesting information purpose:
Disclosure format (paper is default if not marked):
By signing this authorization form, I understand that:

Request for copies of medical records are fees in accordance with federal/state regulations.

I have the right to revoke this authorization at any time. Revocation must be made in writing and presented to the Office Manager at the following address: 3277 S Lincoln Street, Englewood, CO 80113.

Unless otherwise revoked, this authorization with expire on the following date/event/condition: If I fail to specify an expiration date/event/condition, this authorization will expire one (1) year from the date signed.

Treatment, payment, enrollment or eligibility for benefits may not be conditioned on whether I sign this authorization.

Any disclosure of information carries with it the potential for unauthorized redisclosure, and the information my not be protected by federal confidentiality rules.
Patient / Authorized Representative Signature *

Clear
Print Name *

First Name Last Name
Relationship to Patient *
If authorized representative.
Date *

Month Day Year
Date
Should be Empty: