Authorization Requesting Health Information FROM Following Entity or Provider
Authorization to Disclose Health Information FOR the Following Patient
Authorization to Disclose Health Information TO the Following Recipient
For the date range of to Or pertaining to
TERM: I understand this authorization is specifically for information created from services provided before my date of signature. Information related to services provided after my date of signature will require an updated authorization. This authorization will expire (insert date or event): If I fail to specify an expiration date or event, this authorization will expire six months from the date on which it was signed.