Release of information form

"*" indicates required fields

Patient Name*
MM slash DD slash YYYY

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:

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.

MM slash DD slash YYYY

STANDARD AUTHORIZATION OF USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

Patient Name*
MM slash DD slash YYYY
Patient Address
I authorize Catalyst Medical Center and Clinical Spa to:
Address
Information to be disclosed:

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.

MM slash DD slash YYYY

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

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