Authorization to Release Confidential and Privileged Information
It is important that health care providers work together. As such, HealthWise Internal Medicine would like your permission to share information when necessary with your medical providers. This information may include copies of any/all of the following: medical records, x-ray and laboratory results, psychiatric records and/or alcohol abuse records, sexually transmitted disease results, records necessary to process insurance claims and any or all medical information that is required for any health case related to utilization review or quality assurance activities. This authorization may also include any and/or all information related to HIV or AIDS counseling or treatment.
If this release pertains to alcohol or drug abuse information, please note that the information being disclosed to the below stated party by this agreement is confidential and is protected by Federal Law. Federal regulations (42C F>R> Part 2) prohibits HealthWise Internal Medicine from making further disclosure of the information without the specific written consent of the patient to whom it pertains or as otherwise permitted by such regulations.
Please indicate the name and phone number of the person and/or provider.
Please indicate the name and phone number of the person and/or provider.
By typing my name below, I am indicating that I understand this consent shall remain in effect for one year from the date of this page or until revoked by me in writing to HealthWise Internal Medicine. I may cancel this authorization to the extent allowed by law. HealthWise Internal Medicine is released from legal responsibility or liability for the release of the above information. If a patient is a minor (under 18 years of age), incapacitated, or adjudicated incompetent, authorization must be signed by next of kin or executor of estate.
