Integrated Medical Weight Loss

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Authorization to Disclose Personal Health Information (PHI) Credit Card Authorization for Integrated Medical Weight Loss Integrated Medical Weight Loss - Policy Acknowledgements New Patient Paperwork Demographics & Health History

Authorization to Disclose Personal Health Information (PHI)

Name & Address

Date of Birth:

Integrated Medical Weight Loss/Yestermorrow PC is authorized to:

Release to

Obtain From

Primary Care Physician Name:

If you have other doctor's you'd like us to be able to obtain records from, please complete this form for each one.

For the Purpose of:

I AUTHORIZE RELEASE OF THE FOLLOWING MEDICAL RECORDS:

I give permission to release ALL my records:

Including records or copies of records relating to the history, diagnosis, treatment or services rendered to me in connection with any condition or disease. This includes permission to release potentially sensitive information which may include treatment of mental illness, HIV, alcoholism, drug use/dependency, sexually transmitted infections (STI), physical or sexual assaults, communications to physicians, RNPs, social workers and/or psychotherapists, psychologists, if any.

I give permission to disclose and/or release ONLY records specifically described below (check all that apply)

Consultations

EKG

History & Physical Outpatient Reports

Emergency Reports

Operative Reports

X-Ray Results

Laboratory Reports

Pathology Reports

Mental Illness

OT / PT

Speech, Audiology

Cardiac Rehab Records

Sexually Transmitted Infections

Alcohol or Drug Treatment

HIV

I release Integrated Medical Weight Loss/Yestermorrow PC, and the recipient/discloser listed above, and any other providers and staff from all responsibility or liability that may arise from this authorization. I may withdraw this authorization at any time by giving written notification to Integrated Medical eight Loss/Yestermorrow PC, provided that I do so in writing.

Patient Signature (or guardian if Minor)

Please type name

Date

* Required field

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