Primary Care Physician

AUTHORIZATION TO OBTAIN, USE AND DISCLOSE PROTECTED HEALTH INFORMATION

Please fill out for your Primary Care Physician

Patient Name*

First Last

Date of Birth*

Home Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax

Consent*

I agree.

I authorize David Penner MD and the named party below to exchange written and verbal information including my protected health information, including medical treatment, mental health treatment, educational information for the purpose of providing psychiatric assessment, diagnosis, treatment, or coordinating care unless specified otherwise below.

Name of Facility and/or Provider*

INFORMATION COVERED UNDER THIS RELEASE*

Entire medical record including mental health, psychological testing, information for referral, and follow-up purposes.
Other

If you chose other above, please specify

The purpose of this disclosure is:*

Medical care - default
Other

If you chose other above, please specify

TERM: Unless otherwise specified this authorization will expire on termination of treatment with Dr Penner or if for a minor, the time at which the minor reaches age 13.

When this authorization expires:

1 year from the date signed (default)
On other date, reason or event

If you chose other above, please specify

By my signature below, I hereby authorize David Penner MD to obtain, use and/or disclose my health information for the term of this Authorization for the specific purposes listed ("At the request of the patient" is sufficient if the patient is initiating this Authorization).

I understand that once David Penner MD discloses my health information to the recipient, David Penner cannot guarantee that the recipient will not redisclose my health information to a third party. Any such third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information. I understand that I may refuse to sign or may revoke (at any time) this Authorization for any reason and that such refusal or revocation will not affect the commencement, continuation, or quality of Dr Penner's treatment of me; except, however, if my treatment by Dr Penner is for the sole purpose of creating health information for disclosure to the recipient identified in this Authorization, in which case Dr Penner may refuse to treat me if I do not sign this Authorization.

I understand that this Authorization will remain in effect until the term of this Authorization expires or I provide a written notice of revocation to David Penner. the revocation will be effective immediately upon David Penner's receipt of my written notice, except that the revocation will not have any effect on any action taken by David Penner in reliance on this Authorization before it received my written notice of revocation.

I have read and understand the terms of this authorization and have had an opportunity to ask questions about obtaining, using and disclosing my health information. By my signature below, I hereby, knowingly and voluntarily authorize David Penner to obtain use and/or disclose my health information in the manner described above.

Name/Signature of Patient*

Date*

OR Personal Representative

Date

Relation

(self, guardian, parent, etc…)

AUTHORIZATION TO OBTAIN, USE AND DISCLOSE PROTECTED HEALTH INFORMATION

Please fill out for your Primary Care Physician

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