Authorization Disclosure Form

Patient First Name

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Patient Last Name

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Birth Date

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Address

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Furnish records to: Family Medical Care, 150 N New Castle St, New Wilmington, PA 16142

Name of Provider/Facility

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Provider Address

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Provider Phone Number

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Provider Fax Number

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Specific description of information to be used or disclosed

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Dates of Service

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Purpose of disclosure

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If you are transferring, kindly indicate reason for transfer

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*Right not to sign. You may refuse to sign this authorization. Refusal to sign this authorization will not affect your ability to obtain treatment by FMC, except in the case of health care that is solely for the purpose of creating health care information for disclosure to a third party (pre employment physical, life insurance physical, life insurance physical, research related care).

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

*Right to revoke. You may revoke this authorization, in writing, at any time by sending written notification to: Family Medical Care, Attn: Office Manager; 150 N New Castle St New Wilmington, PA 16142

I understand that a revocation is not effective to the extent that the provider has relied on the use or disclosure of the protected health information. Re-disclosure. Health information disclosed pursuant to this authorization may be subject to re disclosure because it is no longer protected by the federal privacy rule or another privacy law. Inspect/Copy. You have the right to inspect or copy the protected health information to be used or disclosed.

This authorization shall remain in effect from the date signed below for 90 days.

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