Betty H Yao, MD APC

Betty H. Yao, MD APC

5185 S. Durango Dr. Ste#1 * Las Vegas, NV 89113 * Phone: 702-933-6530 Fax: 702-933-6533

Authorization to Disclose Protected Health Information (PHI) YOU MUST PROVIDE COMPLETE MAILING ADDRESS OR THIS FORM WILL BE RETURNED TO YOU.

Patient's Name: * Date of Birth: * Chart Number: Complete Mailing Address: *

1. I authorize the use or disclosure of the above named individual's Protected Health Information as described below. 2. The following individual or organization is authorized to mak the disclosure:

Physician Name: * Complete Address: * Phone: * Fax: * The type and amount of information to be used or disclosed is as follows: (include dates where appropriate) * Dates of information requested: * I GIVE PERMISSION TO RELEASE ANY INFORMATION REGARDING: * Reason For Request: *

I understand that I have a right to revoke this authorization I must do so in writing and present my written revocation to the medical record department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

Unless otherwise revoked, thisauthorization will expire on the following date, event or condition: *

If I fail to specify an expiration date, event or condition, this authorization will expire in six months.

This information will be disclosed to and used by the following individual or organization:(print full name of individual/organization, address, phone and fax number) *

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries a potential for and unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have any questions about disclosures of my health information, I can contact the office to obtain a copy of the privacy notice

Signature of Patient: * Date: * Signature of Parent/Guardian or personal Representative(if necessary): *

PURSUANT TO N.R.S 629.061.

THERE WILL BE A CHARGE OF $0.60 PER PAGE WHEN RELEASING RECORD DIRECTLY TO THE PATIENT. PLEASE ALLOW 3-4 WEEKS FOR PROCESSING. FAILURE TO PROVIDE US WITH THE ABOVE INFORMATION WILL PREVENT THIS TRANSFER FROM BEING PROCESSED.