AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
(Complete in full. See reverse side for important information.)
I authorize the use and/or release of my protected health
information as described below. I understand that the information
used or released as a result of this Authorization may no longer be
protected by federal privacy laws and may be further used or
released by persons or organizations receiving it without
obtaining my authorization.
I may refuse to sign this
Authorization, which will not affect my ability to obtain treatment
or payment of claims.
I have the right to revoke this
Authorization by providing written notice to Dean Health System,
Health Information Services Department. Revocation of this
Authorization will not affect any action taken before receipt of
the written revocation.
Name of Patient
City, State, Zip code
Date of Birth
TO RELEASE PROTECTED HEALTH INFORMATION TO:
(If Release is to Self, State Self)