Medical Information Release Form
Date of Birth
CF Care Center
1. Release of Information
Authorization for Use or Disclosure of Protected Health Information- Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 & 164.
I authorize Attain Health to use and disclose my protected health information with my cystic fibrosis care team.
2. Effective Period
Files will only be shared while a client is engaged with Attain Health. Once a client has completed the program they will need to request them to be sent to their clinic if that is desired.
3. Extent of Authorization
This Authorization for release will cover a client's enrollment in the program, their goals and weekly charting notes and blood sugar/food logs.
Please confirm the information Attain Health can share with your clinic:
4. I understand that:
I have the right to revoke this authorization, in writing, at any time.
5. I understand that:
My treatment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.
I allow my clinic to collaborate via phone or email with Attain Health when applicable, to benefit my healthcare.
Date of Authorization
Should be Empty: