Authorization to Disclose Protected Health Information
To a Person Involved in Patient’s Care
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:
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.
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