Patient Authorization for Use and Disclosure of Protected Health Information
The information on this form is used to facilitate our communications to you as we strive to provide you with excellent service.
The provision of this information is optional.
(please print clearly)
Date of Birth
Apt. #/P.O. Box # (Please include complete mailing address)
Medical Record #/Social Security# (optional)
Primary Contact Number
If we cannot reach you at the telephone number listed above, WellStar may contact you (including leaving messages)
regarding appointments or normal lab results at the following number(s):
Cell Phone Number
Other Phone Number
I authorize the WellStar Medical Group to disclose Protected Health Information to the following persons:
Information to be disclosed
All Medical Information
All Billing/Account Information
I understand that Protected Health Information (PHI) used or disclosed pursuant to this Authorization may be
subject to re-disclosure by the recipient and no longer protected by Federal or State Law. I understand that I have the right to revoke this
authorization at any time. I understand that in order to revoke this authorization, I must do so in writing and present my revocation to the
WellStar location where I received care. I understand that the revocation will not apply to information that has already been used or disclosed in
response to this authorization. I understand that WellStar cannot require me to sign this authorization as a condition of treatment unless the
provision of health care by WellStar is solely for the purpose of creating PHI for disclosure to a third party legally authorized to receive such
information. I understand that I will be given a copy of this authorization.
(date authorization signed by patient or Legal Guardian/Personal Representative) _________________________________
Print Patient Name or Name of Legal Guardian/Personal Representative
Signature of Patient or Legal Guardian/Personal Representative
Indicate relationship to patient (required)
This authorization is valid until written notice is provided to revoke this authorization.