Authorization for Release of Protected Health Information

Authorization for Release of Protected Health Information
I (patient indicated below) authorize Southtowns Family Practice to release my information to the following Facility (also indicated below).
Patient Name*
Date of Birth*

MonthDayYear
Social Security Number
Name of Facility to Release Information TO:
Address
Name of Facility to Release Information FROM:
Address
Please select how you would like your information to be delivered

MailFaxPick up
Fax Number
Pick up on
Protected Health Information to be Disclosed
I authorize all information in my medical record from (date) to (date) to be disclosed according to the terms of this Authorization.
Initial One of the Following
I consent to the disclosure of any information pertaining to alcohol abuse, drug abuse, psychiatric condition, any condition related to sexually transmitted disease and/or HIV (Human Immunodeficiency Virus) and AIDS (Acquired Immune Deficiency Syndrome).
I do not consent to the disclosure of any information pertaining to alcohol abuse, drug abuse, psychiatric condition, any condition related to sexually transmitted disease and/or HIV (Human Immunodeficiency Virus) and AIDS (Acquired Immune Deficiency Syndrome).
For the purpose of:

Continued CarePersonal UseOther
1. This authorization shall be in full force and effect for sixty (60) days from the date of the signing, at which time this authorization shall expire.

2. My permission is extended only for the purpose as stated on this authorization and I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to Southtowns Family Practice at 3040 Amsdell Road, Hamburg, NY 14075. I understand that a revocation is not effective to the extent that Stark Medical Specialties has relied on the use or disclosure of the protected health information.
3. I understand that I will be responsible for any charges incurred for the copying and/or faxing of my medical record as permitted by law.
4. I understand that information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. If Southtowns Family Practice is receiving the information, Southtowns Family Practice will only use or disclose the information as permitted by law or as authorized by you.

5. Southtowns Family Practice will not condition my treatment on whether I provide authorization for the requested use or disclosure.

6. I understand I have the right to refuse to sign this authorization. I further understand that I have the right to inspect or copy the protected health information to be used or disclosed as permitted under law.
Signature of Patient or Guardian

Clear
Relationship to Patient (If Applicable)
Address
Home Phone
Work Phone
Date

MonthDayYear
Q
K
Bundle
Should be Empty:

Authorization for Release of Protected Health Information

Protected Health Information to be Disclosed

Initial One of the Following