ADI (Authorization to Disclose Patient Information)

Authorization to Disclose Patient Information

Phone: 952-314-4448
Preferred Name:*
Legal First Name:*
Legal Last Name:*
Phone Number*
Please enter a valid phone number.
Date*

MonthDayYear
Address:
Email Address:
example@example.com
I authorize PrimeCare to*

Share billing/insurance informationMake/cancel/change appointmentsShare protected health informationCommunicate with the patient at the receiving party's phone number (see below)Other
Please use ROI form for all records releases.

with this Receiving Party:
Name*
Phone Number:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to Patient:*
This authorization lasts for one year after the date you sign it unless you enter a different date or expiration here:

MonthDayYear
Date
- This authorization may be cancelled in writing at any time. A cancellation will not change releases that happen before the
- cancellation. A photocopy/fax of this authorization will be treated in the same way as an original.
- PrimeCare may include records that it received from other organizations. If these records have been used by PrimeCare and filed in the record PrimeCare maintains about you, these records may be released with your PrimeCare records. PrimeCare cannot prevent redisclosure of your information by the person or organization who receives your records under
- this authorization, and that information may not be covered by state and federal privacy protections after it is released. By signing this authorization, you release PrimeCare from any and all liability resulting from redisclosure by the recipient.
Your signature indicates that you have read and understand this form, and authorize release of your information as described above.
Signature*

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Date*

MonthDayYear
Date
Should be Empty: