Betty H Yao, MD APC

Authorization to Use and Disclose Protected Health Information

Authorization to release the protected health information of: **Please fill out all fields with a (*) mark.**

Patient Name: *

Please type full name (first, last, M.I.)

Date of Birth: *

mm/dd/yyyy

Current Address: *

full address, city, state and zip code

Phone Number: *

example: 702-933-6530

This authorization is to release the protected health information to:

Facility/ Provider Name: *

example: Dr. John Dinglehopper

Phone Number: *

ex.) 702-933-6530

Deliver by: *

Mail

Fax

Please provide fax and/or mailing address below

Fax Number:

example: 702-933-6530

Mailing address

full address, city, state and zip code. (please note a fee of $0.60 per page for any copies of records)

The purpose of this discloure is: *

Dates of service requested: *

example: from mm/dd/yyyy-mm/dd/yyyy

Release the following information:

Patient Health Information: *

Other Protected Health Information as specified: *

This Authorization will remain in effect: *

Unless otherwise noted above this authorization will remain in effect 180 days from the date signed.

I understand that: *

* Once "this facility" discloses my health information by my request it cannot guarantee the the Recipient will not re-disclose my health information to a third party. The third party my not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information.

*I may make a request in writing at any time to "this facility" to inspect and/or obtain a copy of my health information maintained at this facilityas provided in the Federal Privacy Rule 45 CFR 164.524.

*This Authorization will remain in effect until the Authorization expires or I provide a written notice of revocation to the Health Information Management/ Medical Record Department, If I revoke this Authorization was in effect.

* I may refuse to sign or may revoke this Authorization at any time for any reason and that such refusal or revocation will not affect the commencement, continuation or quailty of "this facility" treatment of me, enrollment in the health plan, or eligibility for benefits.

* Substance Use Disorder treatment records are protected by Federal Rule 42 CFR, part 2. Both a minor's and a parent guardian's signature must be obtained prior to disclosing the minor's Substance Abuse Disorder records.

*If I have questions about disclosure of my health information, I can contact the facility/clinic Medical Record Department, or call 702-933-6530

E-Signature of Patient or Personal Representative: *

By typing your name you authorize the above facility to disclose your protected health information on your behalf.

If signed by personal Representative, Relationship to the above patient *

(if you type "self", or if other type name and relationship to the above said patient.)

Today's Date: *

Available Forms

HIPPA

Authorization to Use and Disclose Protected Health Information

This authorization is to release the protected health information to:

Release the following information: