belladorahealth.com - Release of Information

Release of Information
Bella Dora Health
I, patient name* (Patient Name), hereby authorize Bella Dora Health to disclose and/or receive my protected health information in accordance with the Health Insurance Portability and Accountability Act (HIPAA).
Person(s) or Organization Authorized to Receive/Exchange Information:
Name*

First NameLast Name
Relationship to Patient*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Information to Be Shared (check all that apply)

Treatment informationDiagnosisAppointment and attendance informationCare coordination and clinical recommendationsBilling and insurance informationOther
Purpose of Disclosure

Continuity of careCoordination of treatmentPatient requestOther
This authorization allows communication by verbal, written, electronic, and telehealth means, including phone, email, secure messaging, and fax.
I understand that:
- This authorization is voluntary and may be revoked at any time in writing, except to the extent action has already been taken.
- This authorization will expire on: blanks or ☐ One (1) year from the date of signature.
- Information disclosed may no longer be protected by HIPAA once released to the recipient, unless otherwise required by law.
Signature*

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Printed Name*
Date*

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Date
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Release of Information