Authorization Release

Your Information
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Patient Information
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Please Provide First name!
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Receiving Practice Information
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Please Provide the name of the practice!
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Please Provide the phone number of the practice!
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Please Provide the street address!
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What’s the purpose of this request?
Authorization of Usage and Disclosure

By Selecting, I Specifically Authorize the Use and/or Disclosure of the Following Health Information And/or Medical Records,
If Such Information And/or Records Exist:

Restrict Disclosure

Do you want to restrict disclosure for any records related to the following?

If no please continue to next step
(Federal regulations require a description of how much and
what kind of information is to be disclosed.)
Consent

I understand that, if the person or entity receiving the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by HIPAA and other federal and state regulations. However, the recipient may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality Requirements

I also understand that, the person I am authorizing to use and/or disclose the information may not receive compensation for doing so.

I, further understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment of my eligibility for benefits. I may inspect or copy any information to be used and/or disclosed under this authorization

Finally, I understand, that I may revoke this authorization, in writing, at any time, provided that I do so in writing, except to the extent that action has been taken in reliance upon this authorization

Your Information

Your Name Shakir
Phone 9143595588
Email [email protected]
Relationship To Patient Self
Upload ID ID

Patient Information

First Name Shakir
Last Name Ansari
Date of Birth 20/02/1990
SSN 22222222222
Send Records Via
Email [email protected]
Sending Practice Information
Name Of Practice RTPMedicalSolutions
Phone Number 9153595850
Street 2717 US-89
City Ogden
State UT
Zip 84414
Receiving Practice Information
Name Of Practice Somebody Else
Phone Number 9153595850
Street 2717 US-89
City Ogden
State UT
Zip 84414
What’s the purpose of this request?
Purpose of request 1
Authorization of Usage and Disclosure

By Selecting, I Specifically Authorize the Use and/or Disclosure of the Following Health Information And/or Medical Records, If Such Information And/or Records Exist:

Authorization of usage and Disclosure 1
Restrict Disclosure

Do you want to restrict disclosure for any records related to the following? If no please continue to next step

Restrict disclosure 1
Consent
I understand that, if the person or entity receiving the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by HIPAA and other federal and state regulations. However, the recipient may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality Requirements
I also understand that, the person I am authorizing to use and/or disclose the information may not receive compensation for doing so.
I, further understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment of my eligibility for benefits. I may inspect or copy any information to be used and/or disclosed under this authorization
Finally, I understand, that I may revoke this authorization, in writing, at any time, provided that I do so in writing, except to the extent that action has been taken in reliance upon this authorization
Confirm your Information
Unless revoked earlier, this
authorization will expire
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Please Provide your Insert date!
Looks good!
Please Provide your name!
Send Request Via
Sending Practice Information
Looks good!
Please Provide the name of the practice!
Looks good!
Please Provide the phone number of the practice!
Looks good!
Please Provide the street address!
Looks good!
Please Provide the city!
Looks good!
Please Provide the state!
Looks good!
Please Provide the zip!
What’s the purpose of this request?
Authorization of Usage and Disclosure

By Selecting, I Specifically Authorize the Use and/or Disclosure of the Following Health Information And/or Medical Records,
If Such Information And/or Records Exist:

Restrict Disclosure

Do you want to restrict disclosure for any records related to the following?

If no please continue to next step
(Federal regulations require a description of how much and
what kind of information is to be disclosed.)
Consent

I understand that, if the person or entity receiving the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by HIPAA and other federal and state regulations. However, the recipient may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality Requirements

I also understand that, the person I am authorizing to use and/or disclose the information may not receive compensation for doing so.

I, further understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment of my eligibility for benefits. I may inspect or copy any information to be used and/or disclosed under this authorization

Finally, I understand, that I may revoke this authorization, in writing, at any time, provided that I do so in writing, except to the extent that action has been taken in reliance upon this authorization

Your Information

Your Name Shakir
Phone 9143595588
Email [email protected]
Relationship To Patient Self
Upload ID ID

Patient Information

First Name Shakir
Last Name Ansari
Date of Birth 20/02/1990
SSN 22222222222
Send Request Via
Email [email protected]
Sending Practice Information
Name Of Practice Somebody Else
Phone Number 9153595850
Street 2717 US-89
City Ogden
State UT
Zip 84414
Recieving Practice Information
Name Of Practice RTPMedicalSolutions
Phone Number 9153595850
Street 2717 US-89
City Ogden
State UT
Zip 84414
What’s the purpose of this request?
Purpose of request 1
Authorization of Usage and Disclosure

By Selecting, I Specifically Authorize the Use and/or Disclosure of the Following Health Information And/or Medical Records, If Such Information And/or Records Exist:

Authorization of usage and Disclosure 1
Restrict Disclosure

Do you want to restrict disclosure for any records related to the following? If no please continue to next step

Restrict disclosure 1
Consent
I understand that, if the person or entity receiving the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by HIPAA and other federal and state regulations. However, the recipient may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality Requirements
I also understand that, the person I am authorizing to use and/or disclose the information may not receive compensation for doing so.
I, further understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment of my eligibility for benefits. I may inspect or copy any information to be used and/or disclosed under this authorization
Finally, I understand, that I may revoke this authorization, in writing, at any time, provided that I do so in writing, except to the extent that action has been taken in reliance upon this authorization
Confirm your Information
Unless revoked earlier, this
authorization will expire
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Please Provide your Insert date!
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Please Provide your name!

Congrats!
You have successfully completed your authorization release paperwork!

Your confirmation number: XXXXXX

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