newageaestheticsandwellness.com - HIPAA Medical Records Release Form

HIPPA Release of Medical Records and Privacy Authorization Form
Today’s Date:

MonthDayYear
Date
Name of Patient
Date of Birth

MonthDayYear
Date
OBTAIN FROM: (Releasing facility)
Dr. D. Jonathan Bernardini
NEW AGE AESTHETICS & WELLNESS
9251 E. PEAKVIEW AVENUE
UNIT G
GREENWOOD VILLAGE, CO 80111
Phone: 303-770-7546
Fax: 720-419-2756
PATIENT INFORMATION REQUESTED:

Last 12 months labsLast 12 months hormone treatmentOther
RELEASE TO: (Receiving facility)
Practice/ Patient Name:
Phone Number:
Please enter a valid phone number.
Fax:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I hereby give the releasing facility permission to disclose my individual identifiable health information as listed below. I understand that this authorization is voluntary; that further treatment cannot be conditioned upon my signing this authorization and that there may be a fee

I understand that I can take back permission to release my medical records at any time, except to the extent that action has been taken to comply with it. I understand that this consent will expire 180 days from the date of my signature unless I provide notice in writing that.
Patient’s Signature:

Clear
Date:

MonthDayYear
Date
Patient’s Name:
Should be Empty:

HIPPA Release of Medical Records and Privacy Authorization Form