HEALTHY STRATEGIES FAMILY DOC, P.A.
6611 E. Central Ave., Ste. E, Wichita, KS 67206-1937
Phone: (316) 858-1351 Fax: (316) 858-1355
Authorization to Use or Disclose Protected Health Information
[Record Release]
Patient Full Name:
*
First Name
Last Name
Patient DOB:
*
-
Month
-
Day
Year
Date
Last 4 of SSN:
*
Patient Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I am authorizing Healthy Strategies Family Doc, PA to:
*
Release Healthcare Information To (send records to)
Obtain Healthcare Information From (get records from)
Exchange Information With (share/converse with)
Provider's Name and/or Facility:
*
City and State
*
Office Phone:
*
Format: (000) 000-0000.
Office Fax:
*
Please enter a valid phone number.
Format: (000) 000-0000.
The following communication or records are requested: (Check all that apply)
Requested Records
All healthcare information in my medical record
Other
I understand the information is subject to special protections under federal and state laws. I am authorizing the disclosure of this information and understand my records may contain (1) PHI related to participation in a federal-assisted drug and alcohol abuse treatment program (2) information relating to diagnosis and treatment of mental or emotional conditions, substance use disorders, other than notes recorded by a mental health professional documenting conversations during counseling sessions and such notes are maintained separately (unless this authorization pertains specifically to psychotherapy notes), and/or (3) information relating to HIV testing, HIV status, or AIDS.
Purpose of Requested Disclosure:
*
New Healthcare Provider
Continuity of Care
Other
This Authorization Expires:
*
12 months from the date signed
Other
I understand that I do not have to sign this authorization in order to receive healthcare benefits (treatment, payment, or enrollment). I understand that I may revoke this authorization in writing at any time. If so, it would not affect any actions already taken by Healthy Strategies Family Doc, P.A. based upon this authorization. I understand that if the person or entity that receives the information is not a healthcare provider or health plan covered by federal privacy regulation, the information described above may be re-disclosed and no longer covered by those regulations. I understand that fees may be charged for preparing and sending copies.
Signature
*
Name of Person Completing Form:
*
Relationship to Patient
*
Please Select
Self
Parent/Guardian
Durable Power of Attorney
Today's Date
*
-
Month
-
Day
Year
Date
Preview PDF
Submit
Should be Empty: