AUTHORIZATION TO USE OR SHARE PROTECTED HEALTH INFORMATION (PHI)

Phone: 417.319.3081 Fax: 1-844-685-0298 760 Short State Hwy P Seymour, MO 65746

The information may be disclosed for the following purpose(s) only:

Continued care

If you need to disclose information for insurance or legal purposes, please contact us for a different form. Please remember our services are not covered by health insurance because we don't provide NPI and ICD codes.

I understand that by voluntarily signing this authorization:

• I as described above for the purpose(s) listed.
• I have the right to withdraw permission for the release of my information. If I sign this authorization to use or disclose information, I can revoke this authorization at any time. The revocation must be made in writing to the person/organization disclosing the information and will not affect information that has already been used or disclosed. Care will not be withheld for authorization or failure to authorize this record release.
• I have the right to receive a copy of this authorization.
• I understand that unless the purpose of this authorization is to determine payment of a claim for benefits, signing this authorization will not affect my eligibility for benefits, treatment, enrollment or payment of claims.
• My medical information may indicate that I have a communicable and/or non-communicable disease which may include, but is not limited to diseases such as hepatitis, syphilis, gonorrhea or HIV or AIDS and/or may indicate that I have or have been treated for psychological or psychiatric conditions or substance abuse. You have the right to refuse disclosure of this information.
• I understand I may change this authorization at any time by writing to the person/organization disclosing my PHI.
• I understand I cannot restrict information that may have already been shared based on this authorization.
• Information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer be protected by the Privacy Regulation. Unless revoked or otherwise indicated, this authorization’s automatic expiration date will be one year from the date of my signature or upon the occurrence of the following event:

We encourage communication between healthcare providers, but this form is optional. It is up to you if you want information shared or received between us and your other health care providers. This authorization allows us to send and/or receive information from your healthcare providers. These forms are valid for one year.

1. Fill out the top section of the form with your information.

2. If you want your healthcare provider to release information to us, please check the box that says “to release the following information to

3. If you want us to release information to your healthcare provider, please check the box that says “request the following information from

Note: You can check BOTH the release and request boxes. This is recommended unless you don’t want information shared.

4. On the next line, write the healthcare providers names and locations. If you have the exact address and fax number, please enter that information. If you do not have this information, try to at least include the city and name of the practice. (i.e. Dr. Robert Ellis; OHA Springfield,

5. Under information to be shared, check “Entire Medical Record” unless you want to specify specific dates of records or specific records under "Other"

6. Sign the bottom of the form if you are the patient. If someone has legal authority for you (i.e. a parent for a minor), then have the legal authority sign and write a description below (i.e. parent

7. Make sure you date the form with the correct date and year or the form will be invalid.

8. If you want the form to be valid for longer than a year, you can specify a specific expiration date.