middletownpodiatry.com - Authorization for Release

Authorization for Release of Protected Health Information
Patient's Name:
Patient's Date of Birth:

MonthDayYear
Date
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email (optional):
example@example.com
I hereby authorize Axis Foot & Ankle to:
Name of Individual/Provider/Facility:
Address:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number:
Format: (000) 000-0000.
Information to be Released:

Other
Purpose of Request:

Other
Delivery Method:
Authorization Terms:
- I understand that this authorization is voluntary and that I may refuse to sign it.
- I understand that I may revoke this authorization at any time by providing written notice to Axis Foot & Ankle, except to the extent that action has already been taken in reliance on it.
- I understand that records released may contain information regarding mental health treatment, drug and alcohol use, HIV/AIDS status, or other sensitive information.
- This authorization will expire one year from the date signed unless otherwise specified:
Expiration Date (optional):

MonthDayYear
Date
Click all that apply
Indicate the name of the office where records are to be sent
Phone Number and Fax Number
This consent may be revoked at any time by writing to Middletown Foot & Ankle by mail or email at info@axispodiatry.com unless our office has already taken action in reliance on this authorization. If not previously revoked, this consent will terminate after 6 months.

Middletown Foot & Ankle will not make decisions concerning treatment, payment, enrollment or eligibility for benefits based on signing, refusing to sign or revoking this authorization.

I acknowledge and understand that uses and disclosures of my protected health information authorized by this document may be subject to redisclosure by the recipient and may not be protected by privacy and confidentiality laws.
Patient's Signature
Date signed:

MonthDayYear
Date
If signed by a legal representative (e.g., parent, guardian, power of attorney):
Name
Patient/Guardian Signature
Date signed:

MonthDayYear
Date
Should be Empty:

Authorization for Release of Protected Health Information