Authorization to Share Protected Health Information

Authorization to Share Protected Health Information with Family and/or Friends
Name of Patient

First NameLast Name
Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
I authorize the Carolina Center for Integrative Medicine, PA to disclose the following protected health information.

I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected information to be disclosed as described in this document by sending a written notification.

I understand that information used or disclosed as a result of this authorization may be subjected to-disclosure by the recipient and may no longer by protected by the Federal or State law.

I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing this authorization.

This authorization shall be in force and effect until revoked by the patient or representative signing the authorization.
I authorize the my protected health information to be shared with the following individuals

First NameLast Name
First NameLast Name
First NameLast Name
Description of information to be released - check all that apply

Medical InformationFinancial InformationLaboratory and Radiology ReportBilling Information
Signature

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Authorization to Share Protected Health Information with Family and/or Friends