Temple Care & Wellness Health Authorization for Release of Health Information Patient Name Date of Birth MM DD YYYY I authorize the use or disclosure of the above named individual’s health information as described below. The following physician or organization is authorized to make the disclosure: I understand that I have a right to cancel this authorization at any time. I understand that if I wish to withdraw this authorization I must do so in writing. I must present my written cancellation to the health information management department. I understand that the authorization withdrawal will not apply to information that has already been released due to this authorization. I understand that the cancellation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. I understand that authorizing the release of this health information is voluntary. I can refuse to sign this authorization. I don’t have to sign this form to receive treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the possibility for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about the disclosure of my health information, I can contact my physician’s office manager. I understand that there may be a charge for costs associated with copying my health information. I hearby authorize Temple Care & Wellness to forward any and all relavent health infortmation for (but not limited to) referrals, imaging orders, labs for testing, and drug screens if relevent to my care plan. Signature of Patient/ Legal Representative (Specify Relationship to Patient) Date MM DD YYYY Signature of Patient/ Legal Representative (Specify Relationship to Patient) Thank you for filling out your information!
