Authorization to Release Protected Health Information

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Client Information
Name*
Date of Birth*
Address*
City*
State*
Zip*
Phone*
Other Phone
I hereby authorize the release/use/disclosure of my health information as it relates to treatment, prognosis, and diagnosis and billing information. Records that may be released include: all medical records pertaining to my medical history. I understand that signing this authorization is voluntary. I understand that any and all records, whether written, oral, or in electronic format, are confidential and cannot be disclosed without my prior written authorization, except as otherwise required by law (e.g., Medicare Law). I understand that a photocopy of this authorization that is delivered in person, by mail, e-mail, or fax is as valid as the original. Please release authorized health information to: Lingraphicare America, Inc. Fax: 1-609-275-1311 103 Carnegie Center Suite 104 Princeton, NJ 08540 This information may be disclosed to and used by the following individual(s):
Name
Relation to Patient
Other
Name
Relation to Patient
Other
Name
Relation to Patient
Other
I understand I have the right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to an employee of Lingraphicare America, Inc. 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. If I do not revoke this authorization, it will automatically expire one year from its signature date. I understand that my records may be subject to disclosure by the recipient and may no longer be protected by federal privacy regulations. I understand that this authorization does not limit the above-named healthcare provider, employees, or agents’ ability to use or disclose my information for treatment, payment, or healthcare operations, or as otherwise permitted by law. Equipment and/or services that have been provided by LCA.
Signature of Client or Authorized Individual*
Date Signed*
MM slash DD slash YYYY
Print Name of Client or Authorized Individual*
Relation to Patient(If Other than Patient)
Other
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Client Information