Clone of Medical Records Release Authorization

Name

First Name(s)Last Name(s)

Date of Birth

You must be 18 years old or older to submit this form.

Email

Confirmation Emailexample@example.com

I , the above mentioned patient, authorize:

Please Provide and Disclose my protected health information from the following provider:

Individual or Facility to recevie my protected health information:

Name

Street Address

CityState

Zip Code

Individual or Facility:

Name

Street Address

CityState

Zip Code

Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Fax Number:

Please enter a valid fax number.Format: (000) 000-0000.

INFORMATION TO BE RELEASED OR OBTAINED (Select the one that applies)

PURPOSE OF DISCLOSURE:

Other

MEDICAL RECORDS TIME RANGE:

From:

Date

To:

Date

This authorization shall expire 365 days from the date signed (below my signature) unless I sooner revoke it.

I understand that I have the right to revoke this authorization, in writing, at any time by sending notification to:

Total Wellness Center

PO Box 3189, Teaneck NJ 07666

medicalrecords@123psychiatry.com

Fax: (201) 353-2514.

I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.

I understand that information used or disclosed pursuant to this authorization may be redisclosed by the recipient and may no longer be protected by federal or state law.

I acknowledge that I will receive a signed copy of this document.

Name of the signer (Patient or Legal Guardian as dully authorized by US courts)

First NameLast Name

If authorized signer, relationship to patient:

Signature

Please verify that you are human

Authorization for Use of Disclosure of Protected Health Information

Section 1: About the patient

Section 2: Authorization Details

Section 3: Protected Information Details

Section 4: Your Consent