Authorization of Release of Protected Health Information

Patient Name __________________________________   SS# ______________________

Address __________________________________________________________________

City _______________________________________ State _______ Zip ____________

Phone ____________________ Date of Birth ___/___/_____ CMP record # ___________

• I understand that this authorization gives my permission to release any PHI that is contained in my Medical Record unless I specifically indicate "NO" next to one or more of the categories noted below:

  ____Substance Abuse Information

  ____Psychiatric/Mental Information

  ____HIV Information

• This authorization is voluntary and being made at the request of the individual.
• The released PHI may no longer be protected by Federal Privacy Laws and may be re-disclosed by the individual or organization authorized to receive the PHI.
• This authorization will automatically expire one year from the date signed.

Effective October 1, 2008 the undersigned will be billed a minimum of $.73 per page and postage, if applicable.

Signed ______________________________________________ Date ______________

(If not patient, state relationship)

Witness _____________________________________________ Date ______________