Authorization for Use and Disclosureof Protected Health Information

AUTHORIZATION

FOR USE AND DISCLOSURE OF
PROTECTED HEALTH INFORMATION

Hereby authorize the exchange of my private healthcare information between

And

Individual 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)

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.

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.

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.

5. I understand that this authorization is voluntary and I have the right to revoke to sign this authorization

Form must be completed before signing.

Clear Signature
Clear Signature