Friends and Family Limited Patient Authorization for Disclosure of Protected Health Information Authorization to release information to friends/family Please print all information. Form must be signed and dated. PDF Version First Name* Last Name* SSN (last four digits)* Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Purpose of request (who will be authorized to receive information) - I authorize the entity identified above to disclose or provide protected health information, about me to the individual/entity listed below. Who will be authorized to receive information (the individual/entity who is to receive your PHI):Individual/Entity Name* Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email PhoneFaxDescription of information to be disclosedI authorize the practice to disclose the following protected health information about me to the entity, person, or persons identified above (Please select "Entire patient record" or check only those items of the record to be disclosed): Entire patient record Description of information to be disclosed Office notes Lab results, pathology reports X-rays Financial history report (previous 3 years only). Nursing home, home health, hospice, and other physician records Record of HIV and communicable disease testing Record of mental health or substance abuse treatment Other Only send the following Purpose of disclosurePlease record the purpose of the disclosure or check patient request Patient Request Other Purpose of disclosure - Other Authorization ExpirationThis authorization will expire at the end of the calendar year, unless you specify an earlier termination. You must submit a new authorization form after the expiration date to continue the authorization. Please list the date of expiration if earlier than the end of the calendar year. MM slash DD slash YYYY You have the right to terminate this authorization at any time by submitting a written request to our Privacy Manager. Termination of this authorization will be effective upon written notice, except where a disclosure has already been made based on prior authorization. The practice places no condition to sign this authorization on the delivery of healthcare or treatment. We have no control over the person(s) you have listed to receive your protected health information. Therefore, your protected health information disclosed under this authorization may no longer be protected by the requirements of the Privacy Rule, and will no longer be the responsibility of the practice. Signature* To sign, please preface your signature with "/s/" to confirm you're signing electronically.Date* MM slash DD slash YYYY