Authorization for Use and Disclosureof Protected Health Information AUTHORIZATIONFOR USE AND DISCLOSURE OFPROTECTED HEALTH INFORMATION Please enable JavaScript in your browser to complete this form.By signing this authorization, I, *Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Hereby authorize the exchange of my private healthcare information between Newton-Wellesley Psychiatry Provider *And Person/Facility *Contact Phone Number *Fax Number Purpose (Please check all that apply and include a short description): *At the Request of the IndividualMedical CareLegal MatterInsuranceOther (Please specify below)Purpose DetailsINFORMATION TO BE RELEASED (Please check all that apply): *Admission/Discharge NoteHistoryInformation to Coordinate CareOther (Please specify below)Info to be Released DetailIndividual or Individual’s Personal Representative MUST read and initial the following statements. 1. I understand that Newton-Wellesley Psychiatry will not condition my treatment, (and applicable payment for my health care, my enrollment in a health plan or eligibility for benefits) on whether I provide authorization for the requested use and disclosure – except in limited circumstances (e.g., if the treatment is research-related or the treatment is necessary for the purpose of creating protected health information for disclosure to a third party such as physical examinations for school, camp, or employment purposes) Initials *2. I understand that I have a right to revoke this authorization at any time. My revocation must be in a written letter addressed to Tracey Young, Operations Manager. I understand that such revocation does not affect any action taken by Newton-Wellesley Psychiatry before Newton-Wellesley Psychiatry received my written notice. Initials *3. I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations or other applicable state or federal laws. Initials *4. I understand that I may see a copy of the information described on this form if I ask for it, and that I may obtain a copy of this form after I sign it. Initials *5. I understand that this authorization is voluntary and I have the right to revoke to sign this authorization Initials *Form must be completed before signing. Patient's Signature * Clear Signature Today's Date *Patient's Name *Signature of Legal Representative (If patient is unable to sign) Clear Signature Today's DateLegal Representative Name:Relationship of Legal Representative to PatientClick to Acknowledge
