Jump to Content

Available Forms

Authorization to Release Protected Health Information
First and Last

By my e-signature below, I authorize the release of the Protected Health Information (PHI) indicated below to Evolutionary Healthcare from:

Release the Following Information:

Authorization Details

Patient Rights

I understand that I do not have to sign this authorization in order to get health care benefits (treatment, payment or enrollment). However, I do have to sign an authorization form: - To receive health care when the purpose is to create health care information for a third party or - To participate in a research study. I may revoke this authorization in writing. If I do, it will not affect any actions already taken by Evolutionary Healthcare based upon this authorization. I may not be able to revoke this authorization if its purpose was to obtain insurance. Two ways to revoke this authorization are: - Fill out a revocation form available from Evolutionary Healthcare or - Write a letter to Evolutionary Healthcare. Once health care information is disclosed, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect the health care information.

By selecting the I agree box, I consent to signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By selecting I agree using any device, means, or action, I consent to the legally binding terms and conditions of this document. I further agree that my signature on this document is as valid as if I signed the document in writing. By electronically signing below, I acknowledge the understanding and acceptance of the terms and conditions set forth in this E-Signature Agreement.
Type your full name
* Required field