Authorization to Disclose Protected Health Information

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I authorize Anchorage Fracture & Orthopedic Clinic to release information to:
Type of Information to Be Disclosed:
The Purpose of This Disclosure Is: (Check One)
Preferred Delivery Method:
Authorization:

*If I do not specify an expiration date, this authorization will expire one year from date signed.

I understand that:

  • Authorizing the disclosure of this information is voluntary. My right to treatment, payment, and enrollment or eligibility for benefits is not contingent on signing this form.
  • I have the right to revoke this authorization at any time by submitting a written request to 3831 Piper Street, Suite S-220, Anchorage, AK 99508. I understand that this will not apply to information that has already been released as a result of this authorization.
  • 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 the person or facility listed above as receiving this information is not covered by federal health privacy regulations, the released information may be re-disclosed and may no longer be protected by federal or state law.
  • The patient’s first copy is complimentary, but there may be a charge for requested records after that, or for medical records released to third parties.

*Enter full name to serve as valid signature.

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