Authorization for release of protected health information

Authorization for release of protected health information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I hereby authorize blanks to release the information identified in this authorization form from the medical records of and provide such information to Why Nutrition, Corp.
Information to be released - covering periods of health care from (date) blanks to (date)blank
Complete Health RecordHistory and Physical ExamLaboratory Test ResultsConsultation ReportsDischarge Summary
Purpose of the requested disclosure of protected health information. I am authoring the release of my protected information for the following purpose “purpose may be at the request of the individual”blanks.
Right to revoke Authorization
Except to the extent that action has already been taken in reliance on this authorization, the authorization may be revoked at any time by submitting l a written notice to blanks unless revoked, this authorization will expire on the following date, or after the following time period or event blank .
Re-disclosure

I understand the information disclosed by this authorization may be subject to re-disclosure by the recipient and no longer be protected by the Health Insurance Protability and Accountability Act of 1996.
Signature of client or personal representative who may request disclosure

I understand that I do not have to sign this authorization, and my treatment or payment for services will not be denied if I do not sign this form. However if services are being provided to me for the purpose of providing information to a third party(ie weight management clinic, fitness for work) I understand that services may be denied if I do not authorize the release of information related to such health services to teh third party. I can inspect or copy the protected health information to be used or disclosed. I hereby release and discharge Why Nutrition, Corp of any liability abs the undersigned will hold Why Nutrition, Corp harmless for complying with this authorization.
Signature

Clear
Description of relationship if not patient blanks.
Should be Empty: