AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION
Patient’s Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Previous Name(s):

First NameLast Name
Last four of your Social Security #:
Date of Request
Date

MonthDayYear
Date
PERSON OR PROVIDER RECEIVING THE RECORDS
I authorize Bottumzup Health and Wellness, LLC to disclose the health information identified below to:
Specialty, if applicable: Provider, Recipient Name of Practice/Facility and Address:
Area Code Phone Number Street Address* Address Line 2* City* State* Zip*
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
HEALTH INFORMATION TO BE RELEASED
Please select the records you authorize Bottumzup Health and Wellness, LLC to release:
If requesting specific records, select all that apply:

Other
PURPOSE OF DISCLOSURE

Other
AUTHORIZATION FOR SENSITIVE HEALTH INFORMATION
I understand that certain health information may require specific authorization for disclosure. By selecting Yes below, I specifically authorize Bottumzup Health and Wellness, LLC to release the indicated information, if such information is contained in my medical record and may lawfully be disclosed under this authorization.
HIV/AIDS-related information, including HIV testing and results:
Mental/Behavioral Health Records:
Substance Use Disorder Treatment Records:
METHOD OF RELEASE
Please indicate how you would like the records released:
EXPIRATION OF AUTHORIZATION
This authorization will expire on the following date or upon the following event:
Expiration Date or Event (optional)
If no expiration date or event is specified, this authorization will expire one year from the date signed, unless otherwise required by applicable law.
PATIENT ACKNOWLEDGMENT AND AUTHORIZATION
I understand that I may revoke this authorization at any time by submitting a written request to Bottumzup Health and Wellness, LLC, except to the extent that action has already been taken in reliance on this authorization.

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy laws, except where redisclosure is otherwise prohibited by law.

I understand that signing this authorization is voluntary and that my treatment, payment, enrollment, or eligibility for benefits generally will not be conditioned upon whether I sign this authorization, except as permitted by law.

By signing below, I acknowledge that I have read and understand this authorization and authorize the release of the health information specified above.
Patient Signature
Who is signing this authorization?
Signature
Date

MonthDayYear
Date
If signed by someone other than the patient:

Please complete the information below.
Authorized Representative Name

First NameLast Name
Relationship to Patient (Examples: Parent, spouse, adult child)
Legal Authority to Act on Behalf of Patient (Examples: Legal guardian, power of attorney, healthcare surrogate)
Authorized representative signature:
Date Signed

MonthDayYear
Date
Should be Empty:

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

If signed by someone other than the patient: