HIPPA Privacy Authorization Form

HIPPA Privacy Authorization Form
Name*
Date of Birth*

MonthDayYear
Do you wish to authorize Carolina Center for Integrative Medicine to release any and all medical information and test results that pertain to you, to someone else.*

YesNo
Aurthorized Person(s)*
I authorize Carolina Center for Integrative Medicine or the medical practice to contact the individual(s) listed above to convey any pertinent information to me, in the event that I am unable to be reached by the practice.

I understand that I may revoke/cancel this authorization by notifying The Carolina Center in writing of my intent to revoke authorization or change the name(s) of the individuals to whom information is to be released.
Signature of Patient/Legal Representative*

Clear
Date*

MonthDayYear
Should be Empty: