• I, the undersigned, hereby authorize Dr. Paul McAllister to disclose certain protected health information about me to:
  • Dr. Paul McAllister is hereby authorized to disclose the following protected health information including:
    demographic data (name, address, birth date, social security number);
    past, present or future physical health (diagnoses, prescriptions, medication history, and patient education materials);
    provision of health care; and past, present, or future payment for health care (bills).

    Dr. Paul McAllister will make a reasonable effort to disclose only the minimum amount of protected health information as related to the date(s) of services, type of services and level of detail.

  • I understand that this request does not apply to:
    (1) certain health information that is not held in Dr. Paul McAllister’s medical records
    (2) psychotherapy notes
    (3) information compiled in reasonable anticipation for litigation
    (4) other health information not subject to the right of access under HIPAA.

    The information may be disclosed for the following purpose(s):. providing health care services, to pay health care bills, and any other use required by law.

    This authorization will expire 90 days after the date of my dismissal from treatment unless expressly revoked by me at an earlier time.

    I understand that Dr. Paul McAllister may not condition my treatment on whether I sign this authorization.

    I understand that if my protected health information is disclosed to someone who is not required to comply with the federal HIPPA regulation, then such information may be re-disclosed by the recipient and may no longer be protected by HIPPA.

    I understand that I may revoke this authorization at any time by delivering a revocation in writing to Dr, Paul McAllister at the address listed below and if I revoke this authorization, it will have no effect on actions already taken by Dr. Paul Mcallister in reliance on this authorization.

    I authorize the disclosure described herein, I have read and understand this authorization. I am the patient listed on this authorization or am authorized to act on the behalf of the patient as the patient's personal representative.

  • Date Format: MM slash DD slash YYYY
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