West Park Medical Group Individual Records Release Authorization printable pdf download

West Park Medical Group Individual Records Release Authorization

WEST PARK MEDICAL GROUP

INDIVIDUAL RECORDS RELEASE AUTHORIZATION

: ______________

_______________

Patient

File #:

We understand that information about you and your health is personal, and we are committed to

protecting the privacy of that information. Because of this commitment, we must obtain your

written authorization before we may use or disclose your protected health information for the

purpose(s) described below. This form provides that authorization and helps us make sure that

you are properly informed of how this information will be used or disclosed. Please read the

information below carefully before signing this form.

USE AND DISCLOSURE COVERED BY THIS AUTHORIZATION

A staff member of our office must fully answer any questions you may have regarding this form.

DO NOT SIGN A BLANK FORM. You or your personal representative should read the

descriptions below before signing this form.

Who will disclose the information? Health information about you may be disclosed by a

physician, nurse or member of our office’s staff.

Who will use and /or receive the information? The person(s) or class of persons to whom you

authorize our office to disclose your health information are (please also provide us with the

address and contact information of those person(s) or class of persons if you are asking us to

send medical records or health information out of our office):

What information will be used or disclosed? The appropriate boxes should be checked below,

and the descriptions should be in sufficient detail so that our office staff can understand what

information may be used or disclosed.

□ All medical information that our office has about you

□ The following specific information:

West Park Medical Group

INDIVIDUAL AUTHORIZATION FORM

Effective 4/4/03

West Park Medical Group Individual Records Release Authorization