Today's Date MM slash DD slash YYYY Patient InformationName(Required) First Middle Last DOB(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Preferred Pharmacy Pharmacy Phone NumberBilling InformationPerson responsible for bill Address (if different) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneIs this person a patient here?(Required)YesNoHIPAAI 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 InformationName(Required) First Middle Last DOB(Required) Description of Information to be ReleasedPlease select the materials to be released pursuant to this authorization. any and all medical records/reports consultation report immunization records other test results (lab/radiology) summary report 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 10/01/2023 to 09/30/2024. 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(Required)Patient, the patient's representative, or patient's guardian (if the patient is a minor or incapacitated adult)Date(Required) BillingBilling Consent(Required)I understand that My Personal Physician is a fee for service concierge practice. All services provided to me will NOT be billed to my insurance and I am responsible for the cost. I agreePatient(Required)Date(Required)
