FORM: Authorization for Disclosure of Health Information

Authorization for Disclosure of Health Information

"*" indicates required fields

Patient Name*

First Last

Date of Birth*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

I authorize the use or disclosure of the above named individual’s health information as described below.
The following individual or organization is authorized to make the disclosure:

Inspire Cares
1500 W Elk Ave Ste 205
Elizabethton, TN 37643
The type and amount of information to be used or disclosed is as follows: (include dates where appropriate).

Untitled

Complete health records

Physical exam

Immunization record

Lab results/X-ray reports

Consultation reports

Other

If "Other", please specify:

I understand that the information in my health record may include information relating to sexually transmitte disease, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.
This information may be disclosed to the following individual(s).

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event, or condition:

Date

Signature of patient or legal representative*

Date*

Signature of witness*

Date*