UPDOX - PATIENT PORTAL

Manish Dixit, M.D., F.A.A.P. 1902 S. US HWY 59, Suite 5 Parsons KS 67357Phone: 620.421.0002 Fax 888.820.2325

Please complete all the answers with an *

Patients Name * Patients DOB: * Patients Address * Hearby authorize DR. Manish Dixit to disclose protected health information to: * For the following purposes * If you answered other: Information to be disclosed * If you answered other

I understand that requested information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment of alcohol and drug abuse. This information will be released unless objection is made by checking the statement below.

Do not release my health records pertaining to:

If the person or entity receiving this information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be disclosed to other individuals or institutions or intuitions and no longer protected by these regulations. You may refuse to sign this authorization. Your refusal to sign will not affect your ability to obtain treatment or payment or eligibility for benefits. You may inspect or copy the protected health information to be used or disclosed under this authorization. For protected health information created as part of a clinical trial, your right to access is suspended until trial is completed. Finally, you may revoke this authorization in writing at any time by sending written notification to M.Dixit LLC. Your notice will not apply to the actions taken by the requesting person/entity prior to the date they receive your written request to revoke authorization.

Signature of Patient or Representative * Todays Date * Relationship to Patient *