Authorization Form – Earthly Balance Perinatal Care

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Section I – Authorization

I,____________(Patient Name) , give my permission for ___________ ,(Company Name) to share the information listed in Section II of this document with the person(s) or organization(s) I have specified in Section IV of this document.

Patient Name

Company Name

Section II - Health Information

I would like to give the above healthcare organization permission to

Disclose my complete health record including, but not limited to, diagnoses, lab test results, treatment, and billing records for all conditions.

Disclose my complete health record except for the following information:
Mental health records
Communicable diseases including, but not limited to, HIV and AIDS
Disclose Alcohol/drug abuse treatment records
Genetic information
Other:

Single Line Text

Form of Disclosure:

Electronic copy or access via a web-based portal
Hard copy

Section III – Reason for Disclosure

Please detail the reason(s) why information is being shared. If you are initiating the request for sharing information and do not wish to list the reasons for sharing, write ‘at my request’.

Section IV – Who Can Receive My Health Information

Name

Organization

Address

Address Line 1

City

State

Zip Code

of for wish

Section V – Duration of Authorization

This authorization to share my health information is valid:

From

Single Line Text

This authorization to share my health information is valid:

All past, present, and future periods
The date of the signature in section VI until the following event:

Single Line Text

I understand that I am permitted to revoke this authorization to share my health data at any time and can do so by submitting a request in writing to:

Name

Organization

Address

Phone Number

Fax Number

Signature of Authorizing Party

Today's Date

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

Section I – Authorization

Section II - Health Information

Section III – Reason for Disclosure

Section IV – Who Can Receive My Health Information

Section V – Duration of Authorization

I understand that I am permitted to revoke this authorization to share my health data at any time and can do so by submitting a request in writing to: