Patient Authorization for Use/Disclosure of Protected Heath Information
This form allows Northern Nutrition to communicate with members or your health care team (physician, therapist, etc.) and/or friends or family members. It is recommended you list your referring and/or primary care physician on this form in the event our office needs to request chart notes, labwork, imaging, etc.
Authorized Individual(s)
I request and authorize Northern Nutrition to share (release and obtain from) health care information, both verbal and written, of the client named above with:
Authorized Individual's Name:
First Name
Last Name
Authorized Individual's Relation to Patient
Please Select
Spouse
Family Member
Healthcare Provider
Friend
Authorized Individual's Address:
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Authorized Individual's Phone Number
Authorized Individual's Fax Number
Add an additional Authorized Provider/Family or Friend?
Yes
No
Authorized Individual's Name:
First Name
Last Name
Authorized Individual's Relation to Patient
Please Select
Spouse
Family Member
Healthcare Provider
Friend
Authorized Individual's Address:
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Authorized Individual's Phone Number:
Authorized Individual's Fax Number:
Authorization
This authorization expires either one year from the date listed below or when the above named client or personal representative revokes this authorization in writing. I understand that I have the right to revoke this authorization at any time. However, my revocation will not have any effect on any actions Libby Hugo, RDN, CDE took before she received the revocation. I understand that once Libby Hugo, RDN, CDE releases the information, the information may be subject to re-disclosure by the party receiving the information and may no longer be protected by federal or state law.
Patient's Name
*
First Name
Last Name
Patient's Email
example@example.com
If you are signing on behalf of the patient as a parent or legal guardian, please enter your name and relationship to the patient below:
First Name
Last Name
Relationship to Patient:
Self
Parent
Guardian
Other
Patient's Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Save
Submit
Should be Empty: