sedabadalyanmd.com - Authorization to Release Form

Authorization to Release Form
In general, the HIPAA Privacy Rule gives individuals the right to request a restriction on the uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications, or that a communication of PHI be made by alternative means or at alternative locations.
I wish to be contacted in the following manner (select all that apply):

Home TelephoneO.K. to leave message with detailed informationLeave message with call-back number onlyWritten CommunicationO.K. to mail to my home address.K. to mail to my work/office addressO.K. to fax to this numberWork TelephoneO.K. to leave message with detailed informationLeave message with call-back number only
Patient Signature*

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Patient Name*

First NameLast Name
Date of birth*

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Authorization to Share Protected Health Information (PHI)
I, Name , Authorization to Share Protected Health Information (PHI) authorize the individuals listed below to receive, discuss, and make inquiries regarding my medical information with my healthcare providers. This includes access to my Protected Health Information (PHI) includes, but is not limited to:

My past and current medical history, diagnoses, treatment plans
Lab results, medications, and billing information
Any other information related to my physical or mental health held by my healthcare provider

This authorization applies in case of emergency or as otherwise needed, and remains in effect unless revoked in writing.
Authorized Individuals
Patient Name:
Date of Birth:

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Date
Signature:

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Authorization to Release Form

Authorization to Share Protected Health Information (PHI)