If you wish to request an authorization to release your records per Section III, Paragraph A of the Notice of Privacy Practices, please complete this section. This section is not required. Treatment, payment, enrollment, or eligibility for benefits (as applicable) will not be conditioned upon signing of this authorization section. You have the right to revoke this authorization at any time by writing to DIN NEUROLOGY AND DALLAS ADHD AND HEADACHE SPECIALIST (NEURO CARE LLC). Authorization can be revoked at any time except to the extent that action has already been taken based on this authorization.
I hereby authorize the following individuals to view, discuss, or receive my information:
Relation to Patient
The above authorization shall be in effect until the earlier of two (2) years after the death of the patient for whom this authorization is made OR the following specified date: Authorization expires on:
If you wish to request a restriction on the release of your records per Section IV, Paragraph D of the Notice of Privacy Practices, please complete this section. This section is not required.
I hereby request the following restrictions on the use and/or disclosure of my information:
By signing below, you acknowledge that you have received read the Notice of Privacy Practices prior to any service being provided to you by the Practice, and you consent to the use and disclosure of your medical information.