Authorization for Disclosure of Protected Health Information

Authorization for Disclosure of Protected Health Information

If patient is 18 years or older, form must be completed & signed by patient. If patient is under 18 years of age, form must be completed & signed by a parent/guardian.
Patient Information
Patient Name:*

First NameLast Name
Patient DOB:*

MonthDayYear
Date
Information to be Disclosed to:
I, the undersigned, hereby authorize Center for New Pathways*

to release copies of medical records to:to obtain copies of my medical records from:
Name of Person or Organization
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Reason for Disclosure

Further Medical Care/SpecialistInsuranceAttorneyDisabilitySchoolPersonal UseOther
If OTHER, please specify:
Information to be Disclosed

Check appropriate box(es)
Information to be disclosed:

Only information related to (specify below)Only the period of events from (specify below)Other - specify below (Billing, Scheduling, etc)Entire Record
Only information related to:
Only the period of events from (date to date):
Other Billing, Scheduling, etc:
If you would NOT like any of the following sensitive information disclosed, check the applicable box(es) below:

Alcohol/Drug Abuse Treatment/ReferralHIV/AIDS-related TreatmentSexually Transmitted DiseasesMental Health (other than Psychotherapy Notes)Psychotherapy Notes ONLY (by checking this box, I am waiving any psychotherapist-patient privilege)
This authorization will expire within 1 year from the date of signature. I understand that I may revoke this authorization by submitting written notice of revocation to Center for New Pathways.
Signature of Patient (if 18 years or older) or Parent/Guardian*

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Printed Name:*
Relationship to Patient:
Forwarding Address (if applicable)
Should be Empty:

Authorization for Disclosure of Protected Health Information

Patient Information

Information to be Disclosed to:

Information to be Disclosed