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Authorization for Use and Disclosure of Protected Health Information

Ann Shippy, MD

I hereby authorize:

Name and address of healthcare provider or releasing facility

To release information to:

Ann Shippy, MD 6836 Bee Cave Rd Suite 114, Austin, TX 78746 Fax: 512-328-0070

Purpose of Disclosure

Information to be Released

Specify content and dates

Acknowledgement of Understanding

I understand the expiration date of this authorization is one year.
I understand that I may revoke this authorization at any time by notifying the providing organization in writing, and it will be effective on the ate notified except to the extent action has already been taken.
I understand that information used or disclosed pursuant to this authorization may be subject to redisclosed by the recipient and no longer be protected by federal privacy regulations.
I understand by authorizing this use or disclosure of information there will be no conditions placed on my health care or payment for my health care.
I understand I will receive a copy of this form after I have signed it.
I understand tat in compliance with MN Statute 144.33 and WI Administrative Code HHS117, I may be required to pay a fee for retrieval and photocopying of records and/or supervising inspection of medical records.
of patient, parent of minor, or personal representative
* Required field