Patient Full Name
Date of Birth
* Check all that apply
I hereby authorize Dr. MA to release my medical informationI hereby authorize Dr. MA to obtain medical information
Release my medical information to:
Obtain medical information from:
Address of Individual or Facility:
Telephone of Individual or Facility:
Information to be Released/Obtained may include:
History and Physical Progress Notes
Outpatient Clinic Records
Emergency Medicine Report
Other Diagnostic Reports
Specific Authorizations: Check all that apply:
I authorize the release of information pertaining to drug and alcohol abuse diagnosis or treatment.I authorize the release of information pertaining to mental health diagnosis or treatment.
I authorize the release of HIV/AIDS testing information.
Purpose of Release/Obtaining Medical Information: Check all that apply:
Coordination of CareContinuity of CareBilling and paymentAt request of client or client representativeOther:
Effective Date of Authorization:
Duration of Authorization:
Please Note: Dr. CI MA, like many other health organizations, physicians, hospitals, and health plans, is required by state and federal law to keep your health information confidential. For full details of Dr. CI MA’s privacy policies, please refer to the Notice of Privacy Practices. If you do authorize disclosure of your protected health information to an individual or organization who is not legally required to keep it confidential, it may no longer be protected by state or federal confidentiality laws.
I understand this authorization is voluntary. Treatment, payment, enrollment or
eligibility for benefits may not be conditioned on signing this authorization except if the authorization is for: 1) conducting research-related treatment, 2) to obtain information in connection with eligibility or enrollment in a health plan, 3) to determine an entity’s obligation to pay a clam, or 4) to create health information to provide to a third party.
Under no circumstances am I required to authorize the release of mental health
I understand that I have the 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 Dr. CI MA and/or the healthcare professional or facility listed above. I understand that the revocation will not apply to information that has already been
released in response to this authorization.
I am entitled to receive a copy of this Authorization.
Signature of Client or Client’s Legal Representative