Authorization for Disclosure of Protected Health Information

Authorization for Disclosure of Protected Health Information

Complete One Form for Each Person/Entity to Whom Information May Be Disclosed
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
1. I authorize the healthcare practitioner , Milan Patel, M.D. and Milan Patel, M.D., P.C. and/or the administrative and clinical staff of the Practitioner to disclose my (or my child’s or my ward’s) protected health information, as specified below, to [name and address of person/entity to receive information]:
Name of Person/Entity to Whom Information May Be Disclosed: *

First NameLast Name
Address of Person/Entity to Whom Information May Be Disclosed: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email of Person/Entity to Whom Information May Be Disclosed:
example@example.com
Fax Number of Person/Entity to Whom Information May Be Disclosed:
Please enter a valid phone number.
Phone Number of Person/Entity to Whom Information May Be Disclosed: *
Please enter a valid phone number.
Relationship of Person/Entity to Whom Information May Be Disclosed: *
I am hereby authorizing the disclosure of the following protected health information:

Psychiatric/Medical Treatment

3. This protected health information is being used or disclosed for the following purposes:

Coordination of Care

4. This authorization shall be in force and effect until one (1) year after the date below at which time this authorization to disclose protected health information shall expire.

5. I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the Practitioner at the address above. I understand that a revocation is not effective to the extent that the Practitioner has relied 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.

6. I understand that information disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by HIPAA or any other federal or state law.

7. The Practitioner will not condition my treatment on whether I provide an authorization for disclosure except if health care services are provided to me solely for the purpose of creating protected health information for disclosure to a third party.
Signature of Patient, or Parent of Minor Patient, or Legal Representative of Patient *

Clear
Responsible Party: Name of Patient, or Parent of Minor Patient, or Legal Representative of Patient*

First NameLast Name
Today's Date*

MonthDayYear
Date
Should be Empty: