Patient Registration Sheet - Lebauer Allergy & Asthma (Page 3 of 3) in pdf

Patient Registration Sheet - Lebauer Allergy & Asthma Page 3

LeBauer Medical Center

Allergy, Asthma & Sinus Care

, MD

A. W

, MD

R. C

, MD

ANJAN

HARMA

HELAN

HRISTOPHER

INKLE

Designated Party Release

You may give LeBauer Medical Center, PLLC written authorization to disclose your

protected health information to anyone that you designate. That may be a family member

or personal representative. If you wish to authorize a person to receive information

regarding your care and/or accounting, please complete the form below. I also understand

that information released under this agreement is not protected from further distribution by

the designated party.

Patient Name:______________________________Date of Birth:_______________

Today’s Date:___________________

At my request, I authorize LeBauer Medical Center, PLLC to disclose my protected

health information to (Enter below the name of person/entity who you designate to

be eligible to receive your protected health information):

Name:_____________________________Relationship:____________________

I understand that I have the right to cancel this authorization at any time. If in the future I wish to authorize

cancellation I may request so in writing. However, if I cancel this authorization, I also understand that

cancellation will not affect any action LeBauer Medical Center, PLLC took in reliance on this authorization

before receipt of written notice of cancellation. I also understand that information released under this

agreement is not protected from further distribution by the designated party.

Authorized Signature

:________________________________________

Today's Date:___________

Patient Registration Sheet - Lebauer Allergy & Asthma Page 3