Patient Consent | Creative Medical Consulting

First name

Last name

Phone

Birthday

Month

Day

Year

I hereby authorize, request, and direct Creative Medical Consulting LLC 111 6th Street, Odessa, Delaware 19730 to:

Disclose to

Receive from

Name of Person/Organization:

Address

Phone

Fax Number:

This information is released for the following purpose and that purpose only. No other use or further disclosure of such information is permitted. Purpose of Disclosure:

I understand that if the specific record information that is the subject of this Authorization contains information relating to HIV infection, AIDS or AIDS-related conditions, alcohol abuse, drug abuse, psychological or psychiatric conditions, or genetic testing, the disclosure I am hereby authorizing will include that information.

I understand that I can revoke my authorization in writing at any time, with the exception that the revocation will not apply to information already released in response to this authorization.

Patient or Guardian signature, if under 18 years old

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Todays Date

Month

Day

Year

This Release of Information demonstrates compliance with the Health Insurance Portability and Accountability Act (HIPAA), Standards for Privacy of Individually Identifiable Health Information (Privacy Standards), 45 CFR 160 and 164, and all federal regulations and interpretive guidelines promulgated there under. Once the requested Protected Health Information (PHI) is disclosed, the Privacy Regulations may no longer protect this information if the PHI recipient elects to redisclose the PHI.

PROHIBITION ON REDISCLOSURE: This information has been disclosed or is being released from records whose confidentiality is protected by Federal Law. Federal regulations (42CFR Part 2) prohibit you from making any further disclosure of this information except with the specific written consent of the person to whom it pertains. A general authorization for the release of medical or other information if held by another party is not sufficient for this purpose.