Authorization for Release of Information

Bonner General Internal Medicine

423 N Third Ave. Suite 110 Sandpoint, ID 83864

Phone: (208) 263-6876

Fax: (208) 263-2033

I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand this authorization is voluntary. I understand if the organization authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations.

The patient or the patient’s representative must read and initial the following statements:

2. I understand that I may revoke this authorization at any time by notifying Bonner General Internal Medicine in writing. It will not have any affect on any actions that were taken prior to the revocation.

(Form MUST be completed before signing)

PROHIBITION OF REDISCLOSURE: This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulations (42 CRF part 2) prohibit you from making further disclosure of this information except with the specific written consent of the person to whom it pertains. A general authorization for release of medical or other information if held by another party is NOT sufficient for this purpose.