HIPAA Authorization for Release of Health Information

Authorization Notice

This form authorizes the use or disclosure of your protected health information (PHI) as described below. Please complete all sections. This authorization is voluntary. Refusing to sign will not affect your treatment at May River Dermatology, LLC, unless otherwise indicated.

Section 1 - Patient Information

Patient Full Name

Please enter the patient full name.

Date of Birth

Please enter the date of birth.

Address Line 1

Please enter the patient street address.

Address Line 2

City

Please enter the patient city.

State

Please enter the patient state.

ZIP

Please enter the patient ZIP code.

Phone Number

Please enter the patient phone number.

Email

Please enter a valid email address.

Section 2 - Person/Entity Authorized to Disclose

The following person or entity is authorized to disclose the patient's protected health information:

Name of Disclosing Entity

Please enter the disclosing entity name.

Address Line 1

Please enter the disclosing entity street address.

Address Line 2

City

Please enter the disclosing entity city.

State

Please enter the disclosing entity state.

ZIP

Please enter the disclosing entity ZIP code.

Phone

Please enter the disclosing entity phone number.

Fax

Section 3 - Person/Entity Authorized to Receive

The following person or entity is authorized to receive the disclosed information:

Name of Receiving Entity

Please enter the receiving entity name.

Address Line 1

Please enter the receiving entity street address.

Address Line 2

City

Please enter the receiving entity city.

State

Please enter the receiving entity state.

ZIP

Please enter the receiving entity ZIP code.

Phone

Please enter the receiving entity phone number.

Fax

Attn / Contact Name / Email

Section 4 - Description of Information to Be Disclosed

Identify specifically what information is to be disclosed. Check all that apply and provide date ranges where indicated.

Preferred Format for Release

Electronic (secure email / patient portal / electronic fax)

Paper (physical mail)

Other

Please select a preferred release format.

Section 5 - Purpose of Disclosure

Reason for Disclosure

Continuity of care / transfer to new provider

Specialist consultation / referral

Second opinion

Workers' compensation claim

Disability / insurance claim

Legal proceedings

Personal records request

At the request of the individual (no further explanation required)

Other

Please select a purpose of disclosure.

Section 6 - Expiration

This authorization must expire. Select one of the following:

Expiration Selection

Specific expiration date

One (1) year from date of signature

Upon completion of the following event

Please select an expiration option.

Note: An authorization with no expiration date or event is defective and cannot be honored.

Section 7 - Required Statements

A. Right to Revoke

You may revoke this authorization at any time by submitting a written revocation to the Privacy Officer at May River Dermatology, LLC. Revocation will not affect any uses or disclosures already made in reliance on this authorization prior to receipt of your written revocation.

B. Treatment Conditioning

May River Dermatology, LLC will NOT condition your treatment, payment, enrollment, or eligibility for benefits on whether you sign this authorization, except as permitted by law in limited research or insurance contexts.

C. Re-Disclosure Notice

Information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient. Once re-disclosed, the information may no longer be protected by the HIPAA Privacy Rule.

Section 8 - Signature

By signing below, I certify that I have read and understand this authorization, that all information is accurate, and that I am authorizing the use and disclosure of protected health information as described above.

Signature of Patient or Representative

Printed Name

Please enter the printed name.

Date

Please enter the signature date.

A copy of this signed authorization will be provided to the patient or personal representative via the patient portal.

Personal Representative Information

If signed by a personal representative, complete the following:

Representative's Relationship to Patient

Description of Legal Authority

Document Reference / Case No.