Authorization Release

By Selecting, I Specifically Authorize the Use and/or Disclosure of the Following Health Information And/or Medical Records,
If Such Information And/or Records Exist:

Do you want to restrict disclosure for any records related to the following?

If no please continue to next step

Location Name
Physician Name

Your Name
Signed Authorization Release	File
Phone Number
Email Address

First Name
Last Name
Patient Date of Birth
SSN

Sending Practice Information

Company Name	AFYA PRIMARY CARE
Contact phone	(386) 837-5590
Street	1215 Eagles Landing Pkwy, Suite #202,
City	Stockbridge
State	Georgia
Zip	30281

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Email
Fax
Not Sure

Name Of Practice
Phone Number
Street
City
State
Zip

Name Of Practice
Phone Number
Street
City
State
Zip

Primary Care Transfer
Personal Information
Other
Legal Follow-up
Disability Insurance
Continued Medical Care

By Selecting, I Specifically Authorize the Use and/or Disclosure of the Following Health Information And/or Medical Records, If Such Information And/or Records Exist:
Transcribed Hospital Reports
Rx History
Office Notes and Reports
Laboratory Reports
Diagnostic Reports
Billing Statements

Do you want to restrict disclosure for any records related to the following? If no please continue to next step
Mental Health Information
HIV/AIDS relate information
HBV, TB or Other Communicable Diseases
Genetic Testing Information
Drug/Alcohol diagnosis
Domestic Violence - Treatment or Referral Information
Non Selected

I understand that, if the person or entity receiving the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by HIPAA and other federal and state regulations. However, the recipient may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality Requirements. I also understand that the person I am authorizing to use and/or disclose the information may not receive compensation for doing so. I, further understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment of my eligibility for benefits. I may inspect or copy any information to be used and/or disclosed under this authorization. Finally, I understand that I may revoke this authorization, in writing, at any time, provided that I do so in writing, except to the extent that action has been taken in reliance upon this authorization.