New Patient Packet Page 4

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5505 Edmondson Pk, Ste 104
100 Springhouse Ct., Ste 100
4720 Traders Way, Ste 600
1370 Gateway Blvd., Ste 110
Nashville, TN 37211
Hendersonville, TN 37075
Thompsons Station, TN 37179 Murfreesboro, TN 37129
Ph (615) 331-5898
Ph (615) 826-2080
Ph (615) 302-1279
Ph (615) 890-9008
Fx (615) 331-5705
Fx (615) 822-3213
Fx (615) 302-5279
Fx (615) 890-0193
PATIENT AUTHORIZATION FOR PRACTICE TO RELEASE
PROTECTED HEALTH INFORMATION TO THIRD PARTIES
I hereby authorize the use or disclosure of my health information as described below. I understand that the
information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer
protected by federal privacy regulations.
________________________________________
__________________________________________
Patient Name
Date of Birth
Practice / Physician providing the information:
Practice / Physician receiving the information:
____________________________________
_______________________________________
____________________________________
_______________________________________
____________________________________
_______________________________________
____________________________________
_______________________________________
All Medical Records at this Facility
Other (Please Specify):_________________________________________________________________
____________________________________________________________________________________
Purpose of the use or disclosure:
At the request of the individual
Changing Physician
Moving
Physician/Staff Request
Other _________________________________
I understand that I have the right to refuse to sign this form and that my refusal will not result in the physician conditioning
the provision of healthcare with the following exceptions:
1. The provision of research related treatment for which protected health information is created, my refusal may
result in the physician declining to provide the research related treatment.
2. The provision of healthcare that is solely for the purpose of creating protected health information for disclosure to a
third party, my refusal may result in the physician declining to provide the service to create said protected health
information.
This authorization will expire on ______________________________ (Expiration Date or Defined Event).
I have the right to revoke this authorization in writing except to the extent that the provider has acted in reliance upon
this authorization. My written revocation must be submitted to the designated Privacy Officer.
Signed by:
___________________________________
___________________________________
Signature of Patient or Legal Guardian
Relationship to Patient
_______________________________________
___________________________________
Print Name of Patient or Legal Guardian
Date

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