Release of Protected Health Information

Authorization to use or disclose protected health information

Patient Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Birthdate *

Date of request

As required by the Privacy Regulations, this practice may not use or disclose your protected health information except as provided in our Notice of Privacy Practices without your authorization.

I understand that my complete records may include medical, psychiatric, medication, psychological, psychotherapy and other information. I expressly agree that these records may be released.

I further understand that drug and alcohol information and HIV/AIDS status may also be included unless I specifically ask to restrict the release of this information below.

I hereby authorize and direct Dr. Kardong and any of her employees to use or disclose my Patient Protected Health Information to the following person(s), entity(s), or business associates of this office listed below: Patient Protected Health Information authorized to be disclosed:

Any and all (standard)
Restrictions/Do Not Release
Specify and describe in detail:
Other
Specify and describe in detail:

For the specific purpose of:

Coordination of care
Transfer of care
Other
Specify and describe in detail:

Release Protected Health Information to: *

Name

Company Name

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Effective dates for this authorization, from:

through:

This authorization will expire at the end of the above period. I understand that the information disclosed to the above entity above may be re-disclosed to additional parties and no longer protected for reasons beyond your control.
The protections offered for Psychiatry are not the same as they are for other providers.

I understand I have the right to revoke this authorization by sending written notice to this office and that revocation will not affect this office’s previous reliance on the uses or disclosure pursuant to this authorization. I also have the right to refuse to sign this authorization, to receive a copy of this authorization and to restrict what is disclosed with this authorization.

I also understand that if I do not sign this document, it will not condition my treatment, payment, enrollment in a health plan, or eligibility for benefits whether or not I provide authorization to use or disclose protected Patient Health Information.

Signature of Patient or Patient’s Authorized Representative *

First

Last

Date *

Authorized Signature of Facility/ Dr. Kardong

First

Last

Date