AUTHORIZATION FOR USE OR DISCLOSURE OF

PROTECTED HEALTH INFORMATION

Purpose of Disclosure: The reason I am authorizing release is:

Person(s) Authorized to Make the Disclosure:

Person(s) Authorized to Receive the Disclosure:

This Authorization will expire on

or upon the happening of the following event:

Authorization and Signature: I authorize the release of my confidential protected health information, as

described in my directions above. I understand that this authorization is voluntary, that the information to be disclosed is protected by law, and the use/disclosure is to be made to conform to my directions. The information that is used and/or disclosed pursuant to this authorization may be redisclosed by the recipient unless the recipient is covered by state laws that limit the use and/or disclosure of my confidential protected health information.

Upload File