Release of Information

Patient Name*

First Last

Patient DOB*

Chart Number

I understand that due to HIPAA and patient confidentiality, because I am a legal adult, I must provide written authorization for any medical information from this office to be shared with anyone other than myself.

By signing this form, I understand that I am giving Dr Susan Mathison and /or other physicians at Catalyst Medical Center as well as the nursing staff authorization to discuss my medical condition to the person or persons I have listed below. I also authorize Catalyst Medical Center business office to discuss my account balance and/or financial status unless I indicate otherwise below.

I authorize release for the following personnel:

Name

Relationship

Name

Relationship

Name

Relationship

Name

Relationship

I understand that this authorization will remain in effect until such time as I ask for the information to no longer be given to the above person or persons. I understand that it is my sole responsibility to notify Catalyst Medical Center of this change. This has been explained to me and I fully understand this authorization form.

Patient Initials*

Date*

STANDARD AUTHORIZATION OF USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

Patient Name*

First Last

Patient DOB*

Patient Address

Street Address Address Line 2 City State ZIP Code

I authorize Catalyst Medical Center and Clinical Spa to:

SEND copies of your record to (or discuss information with) the provider/person/facility below

RECEIVE copies of your medical record from (or discuss your information with) the provider/person/facility below

Name of Provider/Facility/Person

Phone Number

Address

Street Address Address Line 2 City State ZIP Code

Fax Number

Information to be disclosed:

Progress Notes

Pathology/Lab Report(s)

Diagnostic Imaging

Operative Notes

Cosmetic Notes

Entire Medical Record

ENT Reports

Dermatology Reports

Allergy Reports

Restrictions: Only medical records originated through Catalyst Medical Center and Clinical Spa will be copied unless otherwise requested. This authorization is valid only for the release of medical information dated prior to and including the date on this authorization unless other dates are specified. The records above may be faxed in case of medical necessity. This authorization may be cancelled at any time by submitting a written request to Catalyst Medical Center and Clinical Spa. This authorization will remain in effect until we have written notice of cancellation.

I have read the above Authorization for release of medical information and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.

Patient Signature*

Date*

Parent or Guardian signature required for any patient under the age of 18

Relationship to Patient (if other than self)

Printed Name of Representative

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Name

This field is for validation purposes and should be left unchanged.

Patient Forms