At Pinnacle Internal Medicine Associates we take every precaution not to disclose protected health information to any entity not involved in your care. We will only release protected health information for treatment, payment and health operations or that which is required by law as discussed in the Privacy Policy that you were given. All other disclosures must have an authorization.

To that effect, we understand that there are times when someone involved in your care may call our office requesting information about your care (for example, medication questions or prescription refills). If there is an individual(s) involved in your care to which you give us authorization to release protected health information, please complete the information below.

Name of Individual(s) that we may release protected health information to and their relationship to you:

Name / Relationship / Their Date of Birth

1.___________________________________________________________________

2.___________________________________________________________________

3.___________________________________________________________________

If there are any restrictions on disclosures to the person(s) listed above, please state the restrictions below:

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

I understand that by my signing below I give authorization for Pinnacle Internal Medicine Associates to release protected health information to the above listed individuals. I also understand that I may revoke this authorization in writing, except to the extent that Pinnacle Internal Medicine Associates has taken action in reliance on the authorization, at anytime as long as that request is given to the Assistant Privacy Officer or the Privacy Officer.

_________________________________________
Print Patient’s Name

_________________________________________ ___________________________
Patient’s Signature Date

_________________________________________ ____________________________
Witness Date