Heartland Podiatry

Authorization to Release Health Information

At my request, HEARTLAND PODIATRY, PC may release the following information:

Entity or person who will receive the information:

This authorization shall be in effect until the information has been forwarded as requested or until the course of treatment is complete.
Patient Rights:
  • I have the right to revoke this authorization at any time.
  • 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 re-disclosure 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.
Signature of Patient or Personal Representative – 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.
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