Authorization to Release Protected Health Information

I, the undersigned, authorize Pain Care Center, its healthcare providers and staff, to release or receive my health information as noted below:

Patient Information
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Address



Release Information
To
From
Address
Purpose of Request

Information to be Released:

Authorization to Release Protected Health Information

I acknowledge and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV results, or AIDS information.

I understand that:
1. I may refuse to sign this authorization and that it is strictly voluntary.
2. My treatment, payment, enrollment, or eligibility for benefits may not be conditioned upon signing this authorization.
3. I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken prior to receiving the revocation. Further details may be found in the Notice of Privacy Practices.
4. If the requestor or receiver is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations and may be disclosed.
5. I understand that I may see and obtain a copy of the information described on this form.
6. I can request a copy of this form after I sign and date it.
7. This release will expire on the date of the earliest of the following events: one year from the signature date, upon a minor’s age of majority and/or upon termination of enrollment in the health plan.

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