Authorization for the Use and Disclosure of Protected Health Information
This authorization is required by the Health Insurance Portability and Accountability Act of 1996 to inform you of yourrights to privacy with respect to your health care information.
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Reason/Information for Release
*
Information to be released
All records
Only records listed below (box will appear when this is checked):
*
Send my OGGI records to recipient below:
Send my OGGI records to recipient email:
I authorize OGGI to receive my records from:
Recipient Email
example@example.com
Recipient Name
*
First Name
Last Name
Recipient Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient/Guardian Signature
*
Date
-
Month
-
Day
Year
Date
Printed Name
*
First Name
Last Name
Relationship to patient (if signing as guardian)
Submit
Should be Empty: