Authorization for Disclosure of Health Information

Patient Information

Last Name: First Name: Middle Initial: Street Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code: Date of Birth: Email Address: Phone Number: Fax Number:

Select an option below

I am requesting Mindpath Health provide me with a copy of my health information. I authorize Mindpath Health to disclose my health information to the Receiving Party specified below. I authorize Mindpath Health to obtain my health information from the Disclosing Party specified below.

Delivery Method

Email (to email address above) Fax (to fax address above) Mail (to address above) Patient portal Verbal communication only

Purpose of Disclosure: The purpose of the disclosure is:

Personal Treatment Billing/Payment Legal Other:

Other (Please specify):

Information to be Disclosed: I authorize disclosure of the following:

Entire Medical Record Treatment Notes from date(s) of service: Billing records Verbal communication only regarding my treatment Other

Only the following specific information (e.g., diagnosis or test results):

Treatment notes from date(s) of service:

Specially Protected Information: I understand that my medical record may contain information that is specially protected by law. I understand that if my medical record contains such information and I do not authorize its disclosure below, Mindpath Health may be unable to fulfill my request. I specifically authorize the disclosure of the following information: