Professional Disclosure Statement - PhoenixWay to Holistic Natural Health

Name *

Email *

Date of Birth *

Name of Insurance Company (or Private Pay) *

Insurance ID# (N/A for Private Pay) *

I hereby authorize PhoenixWay to Holistic Natural Health to use/disclose specified information regarding my services to:

Party to disclose PHI to *

Name, address, phone, fax

Purpose of disclosure *

Referral Coordination of care Consultation Court subpoena

Specific PHI to disclose *

Demographic information Evaluations/Diagnoses Treatment plans Treatment recommendations Treatment history Treatment notes Substance use information

The specific PHI to be used/disclosed shall include only the minimum information necessary to assist in the above stated purpose.

I understand the information to be used/disclosed may be communicated in written, verbal, or electronic form.
I understand that substance use information is protected by federal regulations and cannot be released without my authorization (above).
I understand the information to be used/disclosed may contain HIV/AIDS information.
In accordance with the doctrine consent, I understand the consent of the information to be used/disclosed, the need for the information, and that there are statutes and regulations protecting the confidentiality of authorized information.
Redisclosure of protected health information in prohibited except as permitted or required by state or federal laws.
I understand that I may revoke this consent in writing at any time except for those actions taken prior to revocation.
I understand that I may refuse to sign this authorization form.
I hereby acknowledge that this consent is truly voluntary.

By signing my name and printing the date in the boxes below, I hereby consent to the terms of this document.

Signature (can use mouse or finger) *

Clear

Date *

Authorization to Disclose Protected Health Information