• Associated Surgeons & Physicians

  • Limited Patient Authorization for Disclosure of Protected Health Information

  • Please print all information. Form must be signed and dated.

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  • Entity Providing Information:

  • Entity Receiving Information:

  • 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: (please provide a written description of the information to be disclosed):

     

  • Purpose of disclosure (please check the purpose of the disclosure or check patient request):

  • Expirations or termination of authorization: This authorization will expire one year from the date of your signature below, unless you specify an earlier termination. You must submit a new authorization after the expiration date to continue the authorization. You have the right to terminate this authorization at any time. You must notify our privacy manager, in writing, if you decide to terminate the authorization prior to the normal expiration date.

  • Right to revoke or terminate: As stated in our Notice of Privacy Practices, you have the right to revoke or terminate this authorization by submitting a written request to our Privacy Manager.

    Non-Conditioning statement: The practice places no condition to sign this authorization on the delivery of healthcare or treatment.

    Redisclosure: We have no control over the person(s) you have listed to receive your protected health information. Therefore, your protected health information disclosed under this authorization will no longer be protected by the requirements of the Privacy Rule and will no longer be the responsibility of the practice.

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  • Patient signature Copies of signed authorizations are available upon request.

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