Release of Information Authorization Form
SFM Clinical Research
I, (Patient Name)
Date of Birth
hereby authorize SFM Clinical Research, LLC to:
Release protected health information
TO
:
Receive protected information
FROM
:
Share protected health information
WITH
:
Name of Facility/Individual
Phone
Fax
Address
City
State
Zip
Records Desired
Office Notes
Diagnostic Tests
Medication List
Labs
Other -
It is understood:
That the recipient of the protected health information under this authorization should not re-disclose the information without a written authorization.
Health Care Provider will not condition the provision of care or receipt of benefits on the signing of the authorization.
Patient will receive a copy of the completed authorization form upon request.
Patient may revoke this authorization by requesting in writing.
This authorization expires (choose one)
30 days from below date
1 year from below date
immediately after this request is fulfilled
Patient Name
Date of Birth
Address
City
State
Zip
Patient Signature
– Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date