AIP Informal Inquiry

MEDICAL HISTORY
Please list all primary medical doctors who have treated you in the past 5 years, including specialty doctors such as cardiologists, gastroenterologists, dermatologists, etc.
1. Name & Specialty of Doctor / Facility, Address & Phone Number, Date Last Seen & Reason for Visit
2. Name & Specialty of Doctor / Facility, Address & Phone Number, Date Last Seen & Reason for Visit
3. Name & Specialty of Doctor / Facility, Address & Phone Number, Date Last Seen & Reason for Visit
4. Name & Specialty of Doctor / Facility, Address & Phone Number, Date Last Seen & Reason for Visit

AUTHORIZATION FOR THE USE OR DISCLOSURE OF HEALTH INFORMATION
I hereby authorize the use or disclosure of my health information. Information disclosed pursuant to this authorization could be re-disclosed by the recipient and may no longer be protected by federal conﬁdentiality law (HIPAA).
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Authorization to Obtain and Disclose Confidential Information

This Authorization is HIPAA compliant.
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Informal Inquiry