General Purpose Form- Limited Patient Authorization for Disclosure of Protected Health Information
Patient Name: _____________________________________________________ Date of Birth: ________________________________________________
Age: ______________________________________________________________ Clinic Location: ______________________________________________
I authorize CareNow to disclose or provide my protected health information to the entity or individual identified below. I understand that in the event the facility is unable to accommodate an
electronic delivery as indicated, an alternate delivery will be provided. I understand there is a level of risk associated with receiving unencrypted electronic media or email and the provider is
not responsible for unauthorized access to the protected health information contained in this type of format. I also understand the facility is not responsible for any risks (e.g., virus) potentially
introduced to any computer / device.
Release to (Please print):
Preferred Delivery Method:
Information to be disclosed (Check all that apply)
Chart Notes / Visit Summary
Itemized Bill / Receipt / HCFA – CMS 1500
Immunizations / TB Results
Worker's Compensation Correspondence
Purpose of disclosure – Please list the purpose of the disclosure or check patient request.
Patient Request Other (please specify) : _________________________________________________________________
Inclusions – I understand the disclosure of individually identifiable health information may include information concerning communicable diseases such as HIV or AIDS testing and/or results, mental
illness information (excluding psychotherapy notes), and drug/alcohol/substance abuse information.
Expirations or termination of authorization – I understand this authorization will expire one year from the date of your signature below, unless I specify an earlier termination. A photocopy of this
authorization will be treated in the same manner as the original and that I will get a copy after it is signed. I must submit a new authorization after the expiration date to continue the authorization. I have
the right to terminate this authorization at any time. I must notify the privacy manager, in writing, if I decide to terminate the authorization prior to the normal expiration date. (Please list an earlier
expiration if less than one year): _________________________
Right to revoke or terminate – As stated in the Notice of Privacy Practices, I have the right to revoke or terminate this authorization, except to the extent that the provider haa taken an action in reliance to
the authorization prior to your termination. You may terminate this authorization by submitting a written request addressed to CareNow Privacy Manager, P. O. Box 9101, Coppell, TX 75019.
Redisclosure – The provider has no control over the person(s) I have listed to receive my protected health information. Therefore, my protected health information disclosed under this authorization will
no longer be protected by the requirements of the Privacy Rule and will no longer be the responsibility of CareNow.
Non Conditioning – There is no restriction of my treatment as a condition for signing this authorization.
Right to Copy – I understand that I may see and obtain a copy of the information described on this form, for a reasonable copy fee, if I request it.
Marketing – I understand this request for protected health information is not for marketing purposes and, in no way, involves the sale of my protected health information. The recipient will not further
exchange the information for financial remuneration.
Patient or Guardian Signature: _________________________________________________ Date: _____________________________
Relationship to Patient: _________________________________________________
Internal Use - Released By : __________________________ Date: _______________ Time: __________ Acct #: _____________________________
Revised 2/2/17
