TFMC Request for Outside Records (HIPAA Release)

The Functional Medicine Center

1415 West NC Highway 54 Suite 125 Durham, NC 27707

phone: 919-578-2323 fax: 833-264-1971

HIPAA Request for Outside Records

**Authorization for Use or Disclosure of Protected Health Information

(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)**

1. I authorize the following group/individual to disclose the protected health information described below to Kathryn Godly, PA-C and The Functional Medicine Center.

Name of Practice you are requesting records from

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Fax

Area CodePhone Number

2. This authorization for release of information covers the period of healthcare from:

All past, present, and future periodsOnly dates specfied below

Start date for records

Date

End Date for records

Date

3. Extent of Authorization (Choose A OR B):

A. I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse).B. I authorize the release of my complete health record with the exception of the following information:Other

4. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.

5. This authorization shall be in force and effect until 24 months from signing.

6. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

7. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.

8. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

Patient's name*

First Name Last Name

Your name (only if patient is minor)

First Name Last Name

Patient's Date of Birth*

Today's Date

Please sign your name with attached stylus or mouse if completing at home. All data on this form is encrypted and is transmitted securely via SSL.*