Authorization to Disclose Protected Health Information

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Please print, complete and sign the Authorization to Disclose Protected Health Information and return it to us, to have your medical record sent to your new provider. 

INSTRUCTIONS

 Name of Patient or Individual. Last name, First name of patient

I authorize the following to disclose the individual's protected heath information:  Susan Wynne, MD

Reason for Disclosure:  Check Treatment/Continuing Medical Care if sending to new provider.

Who can receive and use the health information?  Complete this with the new provider's name, address, phone #, fax #.

What Information Can Be Disclosed?  Check All Health Information and INITIAL next to Mental Health Records. 

First Signature line-Signature of Individual or Individual's Legally Authorized Representative: Patient 18 or older or Parent/Guardian of minor child needs to sign and date.

Below signature line: Printed Name of Legally Authorized Representative (if applicable), and check one: parent of minor, guardian, other.