HIPAA Release of Information

HIPAA Release of
Information- Email scanned document to [email protected]

Patient name

Date of birth of patient

1. I authorize Healthy Results, LLC (c/o of my previous provider Dana Dameron, DO ABIM) to release and disclose the protected health information described below to:

Name

Address

Fax

2. This authorization for release of information covers the period of healthcare from:

All past, present, and future periods**OR**

Fromto

3. I authorize the release of:

My complete health record with the exception of the following information:Mental health recordsCommunicable diseases (including HIV and AIDS)Alcohol/drug abuse treatmentOther (please specify):

4. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.

5. This authorization shall remain in force and effect, and that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has legal right to contest a claim.

6. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

Signature of patient or personal representative

Patient's Date of Birth

Printed Name

Date

This is an automated AI email for retrieving patient medical records. It is not monitored by a person.

HIPAA Release of Information

HIPAA Release ofInformation- Email scanned document to [email protected]

HIPAA Release of
Information- Email scanned document to [email protected]