Ohio Holistic Healthcare

570 North Leavitt Road

Amherst, OH 44001

(440) 340-1970 (phone)

(440) 370-3026 (fax)

www.ohioholistichealthcare.com

ohhc2018@gmail.com

Communication Release of Information

*Complete and Bring to Appointment

The Privacy Rule generally requires healthcare providers to take reasonable steps to minimize the Protected Health Information (PHI) requests, usage and disclosure for only what is required to meet the intended need. These provisions do not apply to uses or disclosures made pursuant to an authorization request by the individual.

NOTE:  Uses and disclosures for reasons other than treatment, payment, or operations may be permitted without prior consent in a medical emergency.

______DO NOT PROVIDE MY health information regarding blood work appointments, and test results to anyone but me.

______I GIVE PERMISSION to provide my health information regarding normal test results in a voicemail message.

Authorized Representatives:

I give permission for the following people listed to receive the following PHI elements as specified below.

Name____________________Relationship____________________DOB_______________

Contact Telephone #____________________

_____Appointments   _____Billing   _____Test Results   _____Discuss my conditions and treatments

Name____________________Relationship____________________DOB_______________

Contact Telephone #____________________

_____Appointments   _____Billing   _____Test Results   _____Discuss my conditions and treatments

Name____________________Relationship____________________DOB_______________

Contact Telephone #____________________

_____Appointments   _____Billing   _____Test Results   _____Discuss my conditions and treatments

Name____________________Relationship____________________DOB_______________

Contact Telephone #____________________

_____Appointments   _____Billing   _____Test Results   _____Discuss my conditions and treatments

My signature below acknowledges that I provided the information above.

Signature of Patient/Legal Guardian________________________________________Date________