HIPAA Authorization for Release of Health Information

By signing this form, I hereby authorize Look New Canaan LLC to use and disclose my protected health information (PHI) as described below.

Receiving Party Full Name

Receiving Party Email Address

Receiving Party Mobile Phone Number

Format: (000) 000-0000.

Type of Records (Check all that apply.)

I understand that if my medical record contains information regarding the following sensitive conditions, I authorize the release for:

The purpose of this disclosure is:

Date

Expiration Event

If no date or event is specified, this authorization will expire one (1) year from the date of signature.

By signing this form, I understand:

1. Right to Revoke. I have the right to revoke this authorization at any time by providing written notice to the healthcare provider. I understand that my revocation will not apply to information that has already been released in reliance upon this authorization.

2. Condition of Treatment. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my signing of this authorization.

3. Potential for Redisclosure. Information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule or other confidentiality laws.

4. Copy of Form. I have the right to receive a copy of this signed authorization.

Date

Hour MinutesAM/PM Option

Is the patient under 18 years of age or have a legal representative?

Patient Name

Patient or Legal Representative Email

Patient Signature

Parent or Legal Representative Name

Parent or Legal Representative Signature

HIPAA Authorization for Release of Health Information

Authorization to Release Information

Receiving Party

Information to be Disclosed

Sensitive Information

Purpose of Disclosure

Expiration

Patient Rights and Understandings

Signatures