Limited Patient Authorization for Disclosure of Protected Health Information

This form is not required – Fill this form out if you want someone to have access to your record. EG: Anyone who would call to request information regarding your prescriptions, medical exam, financial, etc. **Please choose which information you’d like to disclose.

*Secure Communication – Note that some fax and email transmission methods are not secure, and it is possible for your PHI to be compromised during transmission from our practice. Do not include a recipient fax number or email if this is of concern to you.

​Our forms are secured using 256-bit encryption and our servers meet HIPAA-complaint standards.

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