Independence Women's Clinic


Authorization for Release of Health Information
Signature Medical Group of KC, P.A.

 
I, or my personal representative, hereby authorize Signature Medical Group of KC, P.A. (Signature) to use or disclose protected health information regarding my care and treatment. I understand that:
  1. Information relating to ALCOHOL/DRUG ABUSE, MENTAL HEALTH TREATMENT, GENETIC TESTING, and/or CONFIDENTIAL HIV-RELATED INFORMATION will not be disclosed unless I specifically authorize such disclosure by placing my initials in the appropriate space(s) in item 8(b).
  2. Information that is disclosed pursuant to this authorization may be re-disclosed by the recipient and no longer protected by federal or state law. If I am authorizing the disclosure of HIV-related information, the recipient is prohibited from re-disclosing the information without authorization, unless permitted to do so under state or federal law. I have a right to request a list of people who may receive or use my HIV-related information without authorization.
  3. I have the right to revoke this authorization at any time by providing a written notice of revocation to the provider at the address listed in item 5 below, except to the extent Signature has already relied upon this authorization.
  4. Signing this authorization is voluntary. Signature may not condition treatment. payment, enrollment in a health plan or eligibility for benefits on my signing or refusal to sign this authorization, except in limited circumstances.
5. Provider Releasing this Information
(one provider per form)
6. Purpose for Release of Information

7. Person(s) to Receive this Information
Send to:
8. Description of Information Being Released
I would like (choose one)




(b.) Include information relating to (initial beside each applicable category):




     (complete a separate authorization form for these notes)
9. Date or event on which this authorization will end

10. Signature:
Release signed by:

By signing below I acknowledge that I have read and agree with all of the above.
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