AUTHORIZATION TO DISCLOSE HEALTH INFORMATION TO LAUREL ENDOCRINE

ERIC HORST, MD . MARJAN KAREGAR, MD . LAURA LABOONE, MD JANELLE HINSON, PA-C MEREDITH EVERETT, FNP - GINA MCKELVEY, FNP
AUTHORIZATION TO DISCLOSE HEALTH INFORMATION
Patient Name*
Date of Birth*

MonthDayYear
Date
I hereby authorize the use of my individual identifiable health information as described below. I understand that this authorization is voluntary. Furthermore, I understand that the released information may no longer be protected by federal privacy regulations.

Medical Care X Legal Representation Other (specify)
Dr./Facility Name*
Dr. /Facility Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dr/Facility Phone #*
Please enter a valid phone number.
Dr/Facility Fax #*
Please enter a valid phone number.
Type of Information Requested*
I understand that I have the right to revoke this authorization at any time. I must revoke this authorization in writing to the privacy officer of this practice. If I revoke this authorization, I understand that the revocation will not apply to information that has already been released. Unless otherwise revoked, this authorization expires upon fulfillment and delivery of information requested.
Signature of PatientLegal Representative*

Clear
Date*

MonthDayYear
Date
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