To,
Recipient’s name:
Recipient’s address:
Date:
I hereby authorize the use and disclosure of any health information as mentioned below. I would like to set forth that I may revoke this authorization at any time by notifying the medical practice. In the event of revocation of this authorization, there will not be any affect on the action taken by the medical practice. I understand that the provision of the form of treatment may not be conditioned on my providing this authorization.
(1) Description of the information to be used or disclosed:
(2) Name of the person or persons authorized to make the requested use or disclosure:
(3) Name of the person or persons to whom the medical practice may is authorized to make the use or disclosure
(4) Expiry date of the authorization:
(5) The authorization may expire in case of the following events:
A B C
Signature of patient
(7) _________________________________ ___________________
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