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  • Authorization to Disclose Protected Health Information

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



  • 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.

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