Common use of Right to Provide an Authorization for Other Uses and Disclosures Clause in Contracts

Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note, we are required to retain records of your care. This notice is effective on May 1, 2014. Again, if you have any questions regarding this notice or our health information privacy policies, please contact Xxxxx Xxxxxxx, M.D. Signature of Patient (or Parent if minor) Relation Date Authorization to Obtain, Use, and Disclose Protected Health Information Patient Name: last first middle Home Address: city state zip Home Telephone: Date of Birth: I authorize Xxxxx Xxxxxxx, MD and the named party below to exchange written and verbal information including my protected health information, including medical treatment, mental health treatment, educational information for the purpose of providing psychiatric assessment, diagnosis, treatment, or coordinating care unless specified otherwise below. Name/Facility:

Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note, we are required to retain records of your care. This notice is effective on May 1, 2014. Again, if you have any questions regarding this notice or our health information privacy policies, please contact Xxxxx Xxxxxxx, M.D. Signature of Patient (or Parent if minor) Relation Date Authorization to Obtain, Use, and Disclose Protected Health Information Patient Name: last first middle Home Address: city state zip Home Telephone: Date of Birth: I authorize Xxxxx Xxxxxxx, MD and the named party below to exchange written and verbal information including my protected health information, including medical treatment, mental health treatment, educational information for the purpose of providing psychiatric assessment, diagnosis, treatment, or coordinating care unless specified otherwise below. Name/Facility:Child’s School: school name counselor’s name Address: city state zip Office Telephone: Fax Number: Information Covered Under This Release Entire medical record