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PatientSignature


 

Patient Request

First Name:  

Last Name:   

Date Of Birth:

Address:

      City: State: Zip:

Phone:

Email:

  1. I authorize and request my physicians, chiropractors, hospitals, surgical centers, and other health care providers who have treated, are treating, or will treat me to send my complete past and current records to Critical Connection Health Foundation and continue to send updated information as it is created, unless this authorization and request is revoked by me in writing.
  2. Purpose for the release or disclosure of Protected Health Information: Pursuant to TITLE 45, PART 164, SECTION 164.508(a)(1) of the CODE OF FEDERAL REGULATIONS, I state that the purpose of this disclosure is for the purpose of continuity of care.
  3. No healthcare provider may condition release of my records on whether I am a current patient or upon payment of my bill.
  4. It is my express intention that this authorization is given in compliance with the HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) (PUBLIC LAW104-191); TITLE 45, PART 164, SECTION 164.508 of the CODE OF FEDERAL REGULATIONS;  I understand that this authorization will be continuing from the date of this authorization unless I otherwise specify.  I desire this authorization to be in effect until revoked. I understand that I may revoke this Authorization by requesting a written revocation of authorization that can be obtained by writing the above-named healthcare provider. I also understand that the written revocation must be signed and dated with a date that is later than the date on this authorization. The revocation will not affect any actions taken before the receipt of the written revocation.

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Signature Certificate
Document name: PatientSignature
lock iconUnique Document ID: 343e1d38ccafbd5a3fd1686aa848c73013f0aa3f
Timestamp Audit
June 27, 2022 12:14 pm CDTPatientSignature Uploaded by Christopher Smith - PatientForms@CriticalConnection.com IP 74.194.174.172
Audit trial Qr code
This audit trail report provides a detailed record of the online activity and events recorded for this document.
https://pdq.patientdataquick.com/
Audit Trail Serial# b90d59f5e0a54cb0a4343251fb8965bb