* = Required Information

Authorization for use or Disclosure of Protected Health Information

I hereby authorize the use and disclosure of my health information as indicated below. I understand that this release is voluntary and that I may revoke this authorization at any time except to the extent that action has been taken in reliance on this authorization. I also understand that if the individual or organization authorized to receive this information is not required to comply with current privacy regulations, my health information may be disclosed to others and no longer protected by current state and federal privacy regulations.

I hereby authorize the release of the information checked and/or listed below for the time period beginning on and ending on :

Nursing Assessments/Notes(s) Physical Therapy Evaluation/Note(s) Occupational Therapy Evaluation/Note(s)
Speech Therapy Evaluation/Note(s) Social Worker Evaluation/Note(s) Laboratory reports
Discharge Summary(s) Photographs Home Health Aide Note(s)
Medication Profile Referral Physician Orders
Plans of Care Billing Claims Complete Healthcare Record

The information checked and/or listed above is to be released to:

for the purpose(s) of: .

The information checked and/or listed above is to be release via the following deliver method:

I hereby authorize the release of the information checked and/or listed below for the time period beginning on and ending on :

I understand that the individual, organization, or entity receiving my health information may receive financial or in-kind compensation in exchange for using or disclosing the information described above.

Unless otherwise revoked by me, I understand that this authorization will expire on or upon the completion of the use of the information for the purpose it was intended, whichever is earlier.

I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment or my eligibility for benefits.

I understand that I may inspect and copy any information used or disclosed under this authorization. I understand that a fee may be charged for such copying and postage services.

I hereby release the provider, its employees, officers, and health care professionals from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

I understand that I may revoke this request at any time by informing the provider with my written notice of such revocation.