Limited Patient Authorization for Disclosure of Protected Health Information (PHI)
Form must be signed and dated each year.
Purpose of request (who will be authorized to receive information) - I authorize the entity identified above to disclose or provide protected health information, about me to the individual(s) listed below.
Description of information to be disclosed - I authorize the practice to disclose the following protected health information about me to the entity, person, or persons identified above:
You have the right to receive a copy of signed authorizations upon request.