Authorization to Release Health Information
Date of Birth
At my request, HEARTLAND PODIATRY, PC may release the following information:
Office visit notes
Note - financial compensation is received for this communication
On site record review by the patient
Note - if this box is checked only psychotherapy notes may be released
Entity or person who will receive the information:
Send the information electronically
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.
This authorization shall be in effect until the information has been forwarded as requested or until the course of treatment is complete.
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