Disclose ROI (RELEASE OF INFORMATION

RELEASE OF INFORMATION:

HIPAA AUTHORIZATION FOR RELEASE OF INFORMATION (DISCLOSE)
Minder Memory Center 415 Laurel St #3030 San Diego CA 92101 phone: (855) 264-6337 contact@mindermemory.com www.mindermemory.com
Date*

MonthDayYear
Date
Patients Name*
Patient Email
example@example.com
Date of Birth*

MonthDayYear
Date
Section I - The Patient
I, (Patient/Parent full name)

First NameLast Name
give my permission for Minder Memory Center to share the information listed in Section II of this document with the person(s) or organization(s) I have specified in Section IV of this document.

Section II - The Authorizations

I hereby authorize the exchange of records, including, but not limited to, diagnoses, test results, treatment, and billing records for all conditions in the form of emailed, photocopied, or faxed reports and/or verbal communication, between Minder Memory Center and the entity(ies) listed in Section III.

Section III - Disclosure

I give authorization for the information detailed in Section II of this document to be shared with the following individual(s) and/or organization(s):
Provider/Facility/Entity Name*
Phone Number
Please enter a valid phone number.
Email
example@example.com
Fax Number
Please enter a valid phone number.
Section IV - Purpose:
The reason for this authorization is:*

General PurposeLegal Purposes (e.g. subpoena, court order, litigation)Other
Other
Section V: Termination

This authorization will terminate 7 years from the date it was signed, or upon sending a written revocation to the Authorization party. I understand that I am permitted to revoke this authorization to share my health data at any time and can do so by submitting a request in writing to Minder Memory Center by sending an email to patient@mindermemory.com.
Section VI - Acknowledgement of Rights

I understand that I have the right to revoke this authorization, in writing and at any time, except where uses or disclosures have already been made based upon my original permission. I might not be able to revoke this authorization if its purpose was to obtain insurance. I understand that uses and disclosures already made based upon my original permission cannot be taken back.

I understand that it is possible that Medical Records and information used or disclosed with my permission may be re-disclosed by a recipient and no longer protected by the HIPAA Privacy Standards.

I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create Medical Records for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization. I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.
Signature of Patient*

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Date*

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Date
Print Name*
(IF THE PATIENT IS UNABLE TO SIGN, USE THE SIGNATURE AREA BELOW)
The patient is unable to sign due to: (check one) - Being a Minor. Patient is years old and considered a minor under state law.

Being a Minor:
Patient is considered a minor, patient age is:
Signature of Representative

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Date

MonthDayYear
Date
Print Name
Relationship to patient:

SpouseParentGuardianOther
Other
Should be Empty:

RELEASE OF INFORMATION: