HIPAA CPE RR RN FORM

Central Park Endocrinology PC

Gregory Dodell MD

Raya Galibov PA

Jimmy Vo MD

Richard R. Neufeld MD

Robert M. Romanoff MD, PC

Patient's Full Name*

Patient’s Social Security # / Medical Record #

Patient's Address*

Street Address

Street Address Line 2

CityState

Zip Code

Patient’s Date of Birth*

Patient's Phone Number*

Format: (000) 000-0000.

I hereby authorize use or disclosure of protected health information about me as described below.

1. The following specific person/class of person/facility is authorized to use or disclose information about me (Ex: Other Medical Facility that has your Medical Information):*

2. The following person (or class of persons) may receive disclosure of protected health information about me:*

Address of Facilty*

Street Address

Street Address Line 2

CityState

Zip Code

Facility Phone #

Please enter a valid phone number.Format: (000) 000-0000.

Facility Fax #

Please enter a valid phone number.Format: (000) 000-0000.

3. The specific information that should be disclosed is (please give dates of service if possible):*

UNLESS YOU SIGN HERE, NO INFORMATION ABOUT ALCOHOL/SUBSTANCE ABUSE, HIV/AIDS, OR MENTAL HEALTH WILL BE DISCLOSED:

YES, DISCLOSE THIS INFORMATION*

NO, DO NOT DISCLOSE THIS INFO*

4. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it and would then no longer be protected by federal privacy regulations.

5. I may revoke this authorization by notifying The Office in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

6. My purpose/use of the information is for Medical Use.

7. This authorization expires on

OR upon occurrence of the following event that relates to me or to the purpose of the intended use or disclosure of information about me:

FEES FOR COPIES: Federal and state laws permit a fee to be charged for the copying of patient records. This facility has contracted with Health Port to make copies. You may be required to pre-pay for the copies; if not, then your copies will be mailed along with an invoice.

THIS FORM MUST BE FULLY COMPLETED BEFORE SIGNING – note that signature is required in two places.

Signature of Individual*

(The person about whom the information relates)

Date of Individual’s Signature

Date of Birth or Social Security Number*

OR, if applicable –

Signature of Guardian* or Personal Representative of Patient’s Estate

Date of Guardian’s / Personal Representative’s Signature

Description of Authority to Act for the Individual

A copy of this completed, signed, and dated form must be given to the Individual or other signatory.

Please verify that you are human*