I hereby authorize Oasis House Call to contact my treating physician(s), hospital(s), home health agency(ies), hospice(s), and any other medical providers to obtain information and/or records concerning my physical or mental condition(s), and for those providers to release the following information to Oasis House Call for the purpose of determining initial or continued eligibility for hospice services, and for continuity of care.

Information to be released will not further be disclosed nor used for any purpose other than that stated in the authorization. This authorization shall remain in effect until which time I am discharged from hospice or otherwise revoke the authorization by written notice.

 

I understand that if the information is disclosed to a third party, the information may no longer be protected by federal privacy regulations and may be redisclosed by the person or organization
that received the information.

 

I understand that I may revoke this authorization at any time by providing written notice or by faxing it to:

Oasis House Call
6965 W Aire Libre Ave
Peoria, AZ 85382
Fax: (623) 251-2851