Authorization to Release Health Information
Patient Name
Date of Birth
Phone
Address
City
State
Zip
At my request, HEARTLAND PODIATRY, PC may release the following information:
Entire record
Financial records
Office visit notes
Marketing
Note - financial compensation is received for this communication
On site record review by the patient
Psychotherapy notes
Note - if this box is checked only psychotherapy notes may be released
Diagnostic studies
Other
Entity or person who will receive the information:
Name
Phone
Address
City
State
Zip
Send the information electronically
For
email communication
I understand that if information is not sent in an encrypted manner there is a risk it could be accessed inappropriately. I still elect to move forward to allow email communications to occur.
Email address:
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.
Description of Personal Representative’s Authority
Date