Forester Haynie


Authorization for the Use and Disclosure of Protected Health Information

1.  I hereby authorize the class of persons identified below to use and disclose protected health information from the record(s) of:

Patient’s Name: ___________________________________________
Date of Birth: ______________________________________________
Social Security Number: ___________________________________

Class of persons authorized to disclose PHI (“Persons Authorized to Disclose”):  All hospitals, clinics, physicians, pharmacy records/history and other health care providers that have records of my past health care and treatment.

___________________________________________________________________________________________________________________
                                                                       (Facility Name and Address)

2.  Copies of the following records shall be used and disclosed:

___  Complete Medical Records; or
___  Other: ______________________________________________________________________

3.  Dates of Service: From: _______________________ To: __________________________

4.  I understand that the records used and disclosed pursuant to this authorization form may include information relating to: Human Immunodeficiency Virus (“HIV”) infection or Acquired Immunodeficiency Syndrome (“AIDS”); treatment for or history of drug or alcohol abuse; or mental or behavioral health or psychiatric care.

5.  I understand that copes of the records indicated above will be (check one):
____  Sent to:                                                                               ____ Faxed to:

Forester Haynie
1701 N Market Street, Suite 210
Dallas, Texas 75202
Facsimile: (214) 346-5909

6.  I understand that the purpose(s) of the use and disclosure is (are):____________________________

7.  Unless otherwise revoked, I understand that the specific date, event, or condition upon which this authorization expires is: __________________________________________________________________________________________

8.  Any facsimile, copy, or photocopy of this authorization shall be as valid as the original.

9.  I understand that I may revoke this authorization in writing at any time except to the extent that the Persons Authorized to Disclose may have already relied on this authorization. I understand that I may revoke this authorization by sending or faxing a written notice to the Persons Authorized to Disclose stating my intent to revoke this authorization.

10.  I understand that my health care providers may not condition treatment on my completion of this authorization form.

11.  I understand that to the extent the recipient of this information is not a “covered entity” under Federal law, the information may no longer be protected by Federal law once it is disclosed to the recipient and, therefore, may be subject to re-disclosure by the recipient.

12.  I understand that I may inspect and copy the information to be used and disclosed pursuant to this authorization form before I sign this authorization form if I ask to do so.

13.  I understand that this authorization is voluntary and that I may refuse to sign this authorization form.

Leave this empty:

Forester Haynie https://foresterhaynie.com
Signature Certificate
Document name:
Unique Document ID: 9e96be28f97c75803874c29a1bfc2897ca0a4dc1
Timestamp Audit
February 21, 2018 10:28 am CST Uploaded by Forester Haynie - matthewhaynie@gmail.com IP 76.185.118.193