Authorization To Release Information 2025

Authorization To Release Information

I herby authorize the release or disclosure of protected health information about me as described below.
Individual Name*

First Name of the individual receiving support from NobleLast Name
Date*

MonthDayYear
Date
Name or identification of the person(s) authorized to receive and/or make the use or disclosure: (Noble/ Noble Team Representatives/ Doctor, etc. ) *
Name or identification of the person(s) authorized to release and/or receive the information: (Who can the information be disclosed to) *
Specific description of the information to be used or disclosed: (What information is being shared)*
The information may be used or disclosed for these purposes:*
I understand that the information used or disclosed may be subject to redisclosure by the person(s) or class of persons receiving it and is no longer protected by federal privacy regulations. I may revoke this authorization by notifying Noble, 7701 E. 21st St., Indianapolis, IN 46219, in writing of my desire to revoke it. However, if I revoke this authorization, it will not have any effect on actions taken by Noble in reliance on this authorization. A copy of this completed and signed form will be provided to me upon request.

This authorization will expire one year from the date below:
Who will be signing this authorization: (Select All that Apply)

IndividualGuardianNoble Employee
Date*

MonthDayYear
Date
Signature of the individual:*

Clear
Guardian Name:

First NameLast Name
Guardian Email:
example@example.com
Guardian Signature:

Clear
Date

MonthDayYear
Date
Noble Employee Name:

First NameLast Name
Noble Employee Email Address:
example@example.com
Should be Empty: