Authorization for Release and to Disclose Consent


Entity to Receive Information

Check each person/entity that you approve to receive information.

Description of information to be released.

Check each that can be given to person/entity.

Patient Rights

  • I have the right to revoke this authorization at anytime.
  • I may inspect or copy the protected health information to be disclosed as described in this document.
  • Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.
  • Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.
  • I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.