Release Form Generic printable pdf download

Release Form Generic

AUTHORIZATION TO RELEASE INFORMATION

To Mansfield Family Practice

Patient Name

Date of Birth

Soc. Sec. #

Patient Address

Phone Number

Name:

TO:

Address:

City

State

Zip

FROM: MANSFIELD FAMILY PRACTICE, 34 Professional Park Rd., Storrs, CT 06268 ~ 860-429-8738

"I hereby authorize this practice to make the use and disclosures of my protected health information as indicated below":

ALL SECTIONS BELOW MUST BE COMPLETED FOR PROCESSING

Description of information to be disclosed (Describe what is to be disclosed. Be specific).

Description of the reason or purpose of this use or disclosure:

This disclosure is being made to:

Dr.

Mansfield Family Practice, LLC

34 Professional Park Road

Storrs, CT 06268

EXPIRATION DATE:

EXPIRATION EVENT:

From (date):_____/_____/_____ To (date:):_____/_____/_____

I understand that I may cancel this Authorization at any time, in writing. If the practice has already used this Authorization or if

this Authorization was used so that I could obtain insurance coverage, I may be unable to cancel the Authorization. I

understand that the practice will not condition treatment or payment based upon my signing this Authorization. I am signing

this Authorization freely. No one has forced me to sign this Authorization. I understand that the information disclosed could be

redisclosed by the recipient, and then it is no longer protected by federal regulations. I understand that if the information

disclosed is related to HIV/AIDS and/or alcohol/substance abuse that the recipient may not redisclose it under Connecticut

State Law. I have reviewed this authorization. I understand it. A copy has been provided to me.

Date:

Patient Signature:

Release Form Generic