Release of Information

Release of Information

Authorization to Use and Disclose Confidential Protected Health Information
As noted below the following are authorized to:
Regarding (Client Name)

First NameLast Name
Date of Birth

MonthDayYear
Date
Name of Person Authorized to Disclose/Receive/Exchange Information
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Purpose of Disclosure- Select one
Information to be Disclosed
Amount of Information to be Disclosed
Other specified amount of information
I understand this authorization remains in effect until the date of expiration. I understand this authorization may be withdrawn any time in writing (except to the extent that action has already been taken). Further release shall cease (except as allowed by law) upon S.P.A.S.M. Acupuncture receipt of the written revocation.
Select one of the following
Specifications (condition/date corresponding to above selection)
Signature
Date signed

MonthDayYear
Date
Should be Empty: