AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION

Patient Information

PHI to be Released

_________ All records or ________________________________________________

_________ All dates or __________________________________________________

Reason for Disclosure

___ Further medical care   ___ Legal inquiry   ___ Insurance   ___ Changing Physicians

___ Personal    ___ Other ___________________________________

This authorization is good until the following date___________________, or for 90 days from the signed date.

I understand that if my PHI is disclosed to someone who is not required to comply with federal privacy regulations, then such information may be re-disclosed and would no longer be protected.

I understand that I have a right to revoke this authorization at any time. My revocation must be submitted in writing. I am aware that my revocation is only effective to the extent that action has not already been taken as a result of my signing this form.

I understand that I do not have to sign this authorization and that my refusal will not affect my ability to obtain treatment from Blue Ridge OB/GYN Associates, nor will it affect my eligibility for benefits. I understand that I have a right to inspect or copy the health information to be disclosed, and I may arrange for such inspection or copying by contacting Blue Ridge OB/GYN Associates. I also have a right to a copy of this signed authorization.

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