AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION Patient
Consent for use and/or disclosure of Protected Health Information (PHI) to Carry out Treatment
Payment and Healthcare Operations.,
As the person signing this authorization, I understand that by signing this Consent, I acknowledge and agree as follows:
I have read and understand the foregoing notice, and all of my questions have been answered to my full satisfaction in a way in which I understand. Initial the following which is applicable:
I do not authorize disclosure of my health information to anyone, other than for treatment, payment and health care operations.
I do not authorize anyone to act as my personal representative.
I authorize you to discuss my health information with the following individual(s) acting as my personal care representative: