INDIVIDUAL PATIENT AUTHORIZATION
This form is to confirm your authorization to use or disclose your protected health information for a special purpose
INDIVIDUAL PATIENT (OR PERSONAL REPRESENTATIVE) CONFIRMING THE AUTHORIZATION
I give my authorization to use and disclose my protected health information as described below. I give this authorization voluntarily.
Last, First
Street, city, state, Zip code
THE USE AND/OR DISCLOSURE AUTHORIZED
Describe information you are authorizing to be used and/or disclosed.
You are authorizing Bethel Medical Clinic to use and /or disclose the protected health information described above.
Who are you authorizing to receive and /or disclose your protected health information.
Describe purpose for authorizing your protected health information to be used and /or disclosed
Date the authorization ends.
I understand that I may revoke this authorization at any time by giving written notice to Dr Obadina
POSSIBILITY OF REDISCLOSURE
I understand that information disclosed under this authorization may be redisclosed by the recipent. Federal privacy rules may not protect the privacy of my health information once the recipient rediscloses my health information.
INDIVIDUAL PATIENT SIGNATURE
I have had the chance to read and think about the content of this authorization form and I agree with all the statements made in this authorization. I understand that, by signing this form, I am confirming my authorization for use and/or disclosure of the protected health information described in this form with the people and/or organizations named in this form.
If this form is signed by a personal representative for the individual patient. Please fill out your name and relationship below.
Name of personal representative
Relationship to patient.
