aspire4w.com - Health Information Informed Release

Authorization to Use or Disclose My Health Information
PATIENT INFORMATION
Name
Date of Birth

MonthDayYear
Date
I authorize to use or disclose my protected health information at my request, including copies of my medical record to the address/facility listed below:
Name of Provider/Facility: Aspire for Women Obstetrics and Gynecology, a Member of OB/GYN Affiliates
Address: 125 Inverness Dr E Ste 210, Englewood, CO 80112 Phone: (303) 221-1490 Fax: (303) 221-1009
Records Transferred From
Physician/Practice
Phone Number
Please enter a valid phone number.
Address
Purpose of disclosure (please specify as required by HIPAA regulations)

Continuing care w/another physician/hospitalTransfer of carePersonal copyOther
Specify here:
I specifically authorize disclosure of the following conditions

Drug AbuseAlcohol AbuseHIV/AIDSPsychological/psychiatric conditions, including psychotherapy notes
Information to be released
  All my health information
My health information relating to the following treatment or condition:   Type a label
  My health information for the date(s):
My Rights
1. I may revoke this authorization at any time by notifying the originating organization noted above in writing.
2. I understand that my revocation does not affect any disclosures made prior to the revocation being received and processed.
3. I understand the information disclosed may be subject to re-disclosure and no longer be protected by federal or state privacy regulations.
4. I have the right to inspect or copy the information to be used/disclosed as permitted by federal law.
5. I may refuse to sign this authorization and that it is strictly voluntary.
6. Authorization will expire 90 days after signature unless indicated otherwise (insert date):
7. If I do not sign this form, my healthcare and the payment for my healthcare will not be affected.
8. If this authorization originated with the provider, I will receive a copy of this form after I sign it.
Signature

Clear
Date

MonthDayYear
Date
Printed Name if signed on behalf of the patient Relationship (parent, legal guardian, personalrepresentative, etc.)
Should be Empty:

Authorization to Use or Disclose My Health Information

PATIENT INFORMATION

Records Transferred From

Information to be released