P0rfners /n Wbment He0/th

600 Her庇Jge Dr. Ste 2ヱO, Jupit∈均FL 33458

Phone停6り-3与4-ヱ5ヱ5

Fox停6り354-ヱ5ヱ6

AUTHORIZA丁ION TO DiSCLOSE PROTECTED HEALTH INFORMATION

P/eo5e COmp/ete 。// sect’ion5 Q声his H/PAA re/eose舟rm.げony sec亡ion5 Ore庫でb/onk, thisform wi// be

invaiid and it w用not be possible foryour hea冊information to be shared as requested.

Section l -Authorization

give mv permission for

to share the information iisted in Section li ofthis document with the person(s) ororganization(s) i have

SPeCified in Section lV ofthis document.

Section lI - Heaith lnformation

l would liketo givethe above heaithcare organization permission to:

口　DiscIose mvcomplete heaith record including, but not “mitedto, diagnoses, labtest results,

treatment, and b帖ng records fora= conditions.

Or

口　Disciose mvcomplete heaith record exceptforthe fo=owing information:

□　Menta川eaith records

口　CommunicabIediseases inciuding, but not limited to, HiVand AIDS

口　DiscioseAicohoi/drug abuse treatment records

□　Geneticinformation

□　Other:

Form of DiscIosu「e:

□　Eiectroniccopvoraccessvia a web-based portaI

□　Hardcopv

Section i‖- Reason fo「 Disciosu「e

Please deta旧he reason(s) whv information is being shared. 1fyou are initiatingthe request forsha「ing

information and do not wish to listthe reasons forsharing, Write ′at my request′・

7輔s documenr w〃 be伯±αined by th叩rov肋1g Orgoniとo亡ion Jbr seven ycar:S.

Pagelof3

Portnerき/n Wbment Heolth

600 Heritoge Dr. Ste 2ヱO, Jupite'FL 33458

Phone停6リー3与4-ヱ与ヱ与

Fax停6り354一ヱ与ヱ6

AUTHORIZATiON TO DISCLOSE PROTECTED HEAしTH INFORMATION

Section lV-Who Can Receive Mv Heaith而ormation

i give authorization forthe heaIth information detahed in section li of帥s documentto be shared with

thefoiiowing individuai(s) or organization(s):

Name:

Organization

Address:

i understand that the person(s)/organization(s川Sted above mav not be covered bv state/federai ruies

goveming privacv and securitv ofdata and mav be permitted tofurthershare the information that is

PrOVided to them.

Section V- Duration ofAuthorization

This authorization to share mv heaith information is va“d:

□　From to

口　Aii past, PreSent,andfutureperiods

口　The dateofthesignature in sectionVl untilthefoilowingevent

l understandthat l am permitted to revokethis authorization tosha「e mv hea冊data atanvtimeand

Can doso bysubmittinga request in writingto:

Name:

Organization:

Address:

i understand that:

● lnthe eventthat mvinformation has aireadvbeen shared bvthetime mvauthorization is

revoked言t mav be too late to cancel permission to share my heaIth data,

' l understandthat i do not need togiveanvfurtherpermissionforthe information detahed in

Section li to be shared with the person(s) ororganization(s) listed in section iV.

・ l understandthatthefa血retosign/submitthisauthorization o「the cance=ation ofthis

authorization wi‖ not prevent me from receiving anvtreatment or benefits l am entitied to

receive, PrOVided this information is not required to determine if l am eiigibieto receive those

treatments or benefits orto pavforthe services l receive.

7航s documen亡wi〃 be融oined by拓e prov肋ng oI卵面eo的nfor seven ye。ぽ

Page3〇千3

P0rtnerき/n Woment Heo/th

600 Heritoge Dr. S亡e 2重りJupiteI声L 33458

Phone停6り-3与4-ヱ与ヱ5

Fax停6リ3与4-ヱ与ヱ6

AUTHORIZATION TO DISCLOSE PROTEC丁ED HEAL丁H INFORMA丁ION

Section VI - Signature

Print Patient Name Date

Signature

ifthisform is beingcompIeted bya person with legai authorityto actan individual’s behalf, SuCh asa

Parent O「 legal guardian ofa minor or heaith care agent, Piease compiete the following information:

Name of person compietingthis form:

Signature of person compietingthis form

Describe below howthis person has legal authoritvto sign this form

7航s documen亡w初be硯α面ed by的e providing o岬clni之。軸onJbr seven yeors.

Page40f3