Circle Care Center & Pharmacy Medical Release Form

Circle Care Center & Pharmacy Medical Release Form

RELEASE/AUTHORIZATION OF USE AND DISCLOSURE OF PATIENT HEALTH INFORMATION
Information authorized to be Used or Disclosed

The information covered by this authorization includes:
Medical/Prescriptions (Excludes psychotherapy notes)

YesNo
Lab Results

YesNo
Persons to whom information may be disclosed:
Print name/Relationship
Expiration Date of Authorization
This authorization is effective Date through Date, unless revoked or terminated by the patient or patient's personal representative.
Right to Terminate or Revoke Authorization

You may revoke or terminate this authorization by submitting a WRITTEN notice to our office.
Potential for Re-disclosure

Information that is disclosed under this authorization may be re-disclosed by the person or organization to which it is disclosed. The privacy of this information may not be protected under the Federal Privacy Rule depending on whom the information is disclosed to.
Name of Patient (Print)*

First NameLast Name
Signature of Patient*

Clear
Date

MonthDayYear
Today's Date
Signature of Patient's Representative (if applicable)

Clear
Relationship of Patient's Representative
Should be Empty:

Information authorized to be Used or Disclosed