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Authorization for Release of PHI
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Authorization for Release of Protected Health Information
45 C.F.R. § 164.508 — Please read carefully before signing.
Section 1 — Patient information
Section 2 — Direction of disclosure
Both directions are selected by default. Uncheck only if one does not apply.
Section 3 — Other party information
Section 4 — Records to be released / received
Section 5 — Purpose of disclosure
Section 6 — Expiration
Section 7 — Your rights
RIGHT TO REVOKE: You may revoke this authorization at any time by submitting a written request to jonah@mindandrelationship.com or (412) 206-9080. Revocation does not affect disclosures already made in reliance on this authorization.
TREATMENT IS NOT CONDITIONED ON SIGNING: Signing this form is voluntary. Your care will not be affected by whether you sign or decline.
RE-DISCLOSURE: Information disclosed under this authorization may be re-disclosed by the recipient and may no longer be protected by federal HIPAA privacy regulations.
TREATMENT IS NOT CONDITIONED ON SIGNING: Signing this form is voluntary. Your care will not be affected by whether you sign or decline.
RE-DISCLOSURE: Information disclosed under this authorization may be re-disclosed by the recipient and may no longer be protected by federal HIPAA privacy regulations.
Section 8 — Signature
By signing below, I certify that I have read and understand this authorization.
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