Earthly Balance Perinatal Care
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Authorization Form
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Home
About Us
Services
Contact Us
Referral Form
Form
New Patient’s Information Sheet
Medical History Form
Authorization Form
(808) 646-3782
Contact Us
AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION
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Patient Name
*
Company Name
*
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.
h
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 can –
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’.
Name
*
Organization
This authorization to share my health information is valid:
From
Single Line Text
To
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
Name
Organization
Address
Fax Number
Signature of Authorizing Party
Submit
