Authorization for Release of Information (Electronic Form)

Nevin Arora MD ~ Kristen LaMarca PhD

www.luciditysleeppsych.com
Authorization for Release of Information
Patient Name*

First NameLast Name
Complete the following section with the contact information of the person or institution with whom you are consenting that we share your information.

"I HEREBY AUTHORIZE LUCIDITY SLEEP PSYCHIATRY TO RELEASE AND EXCHANGE MY HEALTH INFORMATION WITH:"
Name of Person or Institution (whom you'd like us to share your information with):*
What is their address?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is their phone number?*

Area CodePhone Number
What is their fax number?

Area CodePhone Number
Check One:*

No limit releaseLimited release (Specify below)
If applicable, release of information is limited to:
e.g. Scheduling, treatment coordination, letter for disability, etc.
This authorization expires on (if date not complete, 1 year after signed)

MonthDayYear
Date
By signing this form, I am authorizing the use or disclosure of protected health information as indicated above. I may revoke this authorization at any time by providing written notice to Lucidity Sleep & Psychiatry. I acknowledge that I fully understand the terms and conditions of this authorization.
Signature of Patient or Legal Representative*

Clear
Your name (Who signed this form?)*

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

Authorization for Release of Information