PH
843.837.4400 |
FAX
843.837.4440
6470 East Johns Crossing, Suite 200
Johns Creek, GA 30097
Herbert Alexander, MD Paola Bonaccrosi, MD Dale Sarradet, MD
AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION TO THIRD PARTY
(Complete this form if you would like for May River Dermatology, LLC to disclose certain protected health information to family members)
I
authorize May River Dermatology, LLC to use and/or disclose certain protected health information (PHI) as described herein. I understand that, if the person(s) or organization(s) that I authorize to receive my protected health information are not subject to federal and state health information privacy laws, subsequent disclosure by such person(s) or organization(s) may not be protected by those laws.
I authorize the following person (s) and/or organization(s) to receive my PHI, as disclosed by the person(s) and/or organizations(s) above.
Name(s) & Relationship(s)
Contact Telephone Number
Organization(s) & Address
Specific description of PHI that I authorize for disclosure (complete medical records, progress notes, labs, photos, etc.):
Specific description of the purpose for each use or disclosure (or write "At the request of the individual" in this space):
This authorization will expire on (date, event, or indefinite):
I have the right to revoke this authorization in writing except to the extent that May River Dermatology, LLC has acted in reliance upon this authorization. My written revocation must be submitted to May River Dermatology, LLC Compliance Officer, 350 Fording Island Rd., Suite 100, Bluffton, SC 29910. I further understand that my eligibility for health benefits, my enrollment in a health plan, and my treatment will not be affected by whether or not I sign this authorization.
I have had the opportunity to read and consider the contents of this authorization. I confirm that the contents are consistent with my direction.
Patient Name (PRINT)
Patient D.O.B
Patient or Legal Guardian Signature
Reset Signature
Relationship to Patient (if other than patient)
Date:
Submit Authorization