Release of Information To BGH Family Practice

Authorization for Release of Information

423 N. Third Ave, Suite 110 Sandpoint, ID 83864 | (208) 265-2221 | Fax # 208-265-2229
I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand this authorization is voluntary. I understand if the organization authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations.
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
MR #
I hereby authorize Bonner General Family Practice to release my health information to:
I hereby authorize Bonner General Family Practice to obtain my health information from:
Specific description of information (including date[s]):
1. I understand that this authorization will expire on Date . Initials Initial here .
2. I understand that I may revoke this authorization at any time by notifying Bonner General Family Practice in writing. It will not have any effect on any actions that were taken prior to the revocation. Initials initial here
Signature of patient or patient's representative (Form MUST be completed before signing)

Clear
Date

MonthDayYear
Date
Printed name of patient's representative:
Relationship to patient
*YOU MAY REFUSE TO SIGN THIS AUTHORIZATION*

PROHIBITION OF REDISCLOSURE: This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulations (42 CRF part 2) prohibit you from making further disclosure of this information except with the specific written consent of the person to whom it pertains. A general authorization for the release of medical or other information if held by another party is NOT sufficient for this purpose.
Should be Empty:

Authorization for Release of Information