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PFAI Release of Medical Information
I hereby authorize the use and disclosure of my individually identifiable health information as described below. I understand that this authorization is voluntary. I understand that if the person or organization authorized to receive the information is not a health plan or health provider; the released information may no longer be protected by federal regulations.
Email address *
Patient Name *
Your answer
Date of Birth *
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Phone *
Your answer
Person/Organization Requesting:
Your answer
Name *
Your answer
Address *
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City *
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State *
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Zip *
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Phone *
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Fax
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Person/Organization Releasing:
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Name *
Your answer
Address *
Your answer
City *
Your answer
State *
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Zip *
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Phone *
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Fax
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Specific description of information (including date(s) of service):
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Purpose of Disclosure (i.e. individual’s request, insurance, continuing care, permanent transfer):
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The patient or patient’s representative must read and initial the following statements: 1. I understand that this authorization will expire on (one year from request). Please enter today's date.
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Initials
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2. I understand that I may revoke this authorization at any time by notifying the practice in writing, but if I do, it won’t have any effect on any actions they took before they received the revocation. initial
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3. I understand that my health care and the payment for my health care will not be affected if I do not sign this form. initial
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4. I understand that my health care and the payment for my health care will not be affected if I do not sign this form. initial
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By signing this Authorization, I acknowledge that I have read it and that I understand it. Type your name.
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Date
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Relationship to patient
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*YOU MAY REFUSE TO SIGN THIS FORM*
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