WARNING - Form Has Not Been Signed - Please confirm this action
Patient Authorization for Use and Disclosure of Protected Health Information
By signing, I authorize Awaken Wellness, LLC to use and/or disclose certain protected health information (PHI) about me to (Print Organization Name - or - indicate Released Directly To Patient)
This authorization permits Awaken Wellness, LLC to release to / receive from (Name of Practitioner) any information regarding my diagnosis, examination and treatment while under your care.
The information will be used or disclosed for the following purpose: (If disclosure is requested by the patient, purpose may be listed as “at the request of the individual”) . This authorization will expire .
I understand that there will be a $.10 charge per page for copies made from my file and I agree to pay this at the time I pick up my PHI.
I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this
authorization. My written revocation must be submitted to the privacy officer at Awaken Wellness, LLC.|
Signature of Patient or Guardian:
(draw your signature)
If Guardian - Relationship to Patient: