My Personal Physician

Covid Clinic

MM slash DD slash YYYY

Patient Information

Name(Required)
Address(Required)
Invoices will be sent to this email.

Billing Information

Please complete if different than above.
Address (if different)

HIPAA

I hereby authorize My Personal Physician to disclose my Protected Health Information (PHI) as contained in the records maintained by My Personal Physician, including, but not limited to highly confidential information concerning communicable diseases, HIV, AIDS, psychiatric, chemical or alcohol dependency, laboratory test results, or any other medical treatment. This authorization does not include psychotherapy notes.

Patient Identification Information

Name(Required)

Description of Information to be Released

Please select the materials to be released pursuant to this authorization.

This authorization includes the release of documents in your possession whether or not created in your office or by another healthcare provider.

This authorization is in effect from 12/03/2022 to 12/03/2023. Upon conclusion of said period, authorization is automatically revoked.

I understand that the information released in response to this authorization is subject to disclosure to other parties, and that any other person, firm, or entity that releases material pursuant to this authorization is released from any liability that might otherwise result from the release of this information.

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 physician or appropriate healthcare provider.

I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand authorization for the use or disclosure of the information Identified above is voluntary. I need not sign this form to ensure healthcare treatment. I further understand that my healthcare and the payment of my healthcare will not be affected if I do not sign this form.

Patient, the patient's representative, or patient's guardian (if the patient is a minor or incapacitated adult)

Billing

Billing Consent(Required)