Helendale Dermatology & Medical Spa 500 Helendale Road, Suite 100 Rochester, NY 14609 585.266.5420 fax 585.266.5423 Authorization for Use and Disclosure of Protected Health Information

This form provides authorization to Helendale Dermatology & Medical Spa to use or disclose certain of your personal health information for the purpose(s) described below. It is intended to properly inform you of how this information will be used or disclosed. You should carefully read the information on this form before signing it.

I,

Date of Birth:

Authorize the Practice to (choose one):

Disclose to:

Obtain From:

Disclose to:

Obtain from:

With an address at:

Choose One Of The Following:

I will continue to be a patient at Helendale Dermatology

Not planning to return

The Following Information:

(if left blank, 2 years of medical history and all pathologies are provided)

The disclosure of any part of the medical record deemed to be “psychotherapy notes” will require a separate authorization. I understand that if my records contain information about alcohol and drug abuse, mental health treatment and/or HIV/AIDS status, I authorize the Practice to release such information as part of my medical record only if I place my initials on the appropriate line as set forth below

Included in information to be released:

Alcohol/Drug Treatment

Mental Health Information

HIV Related Information

Purpose of Information to be Disclosed [If you have requested the use or disclosure of the information but do not, or elect not to, provide a statement of the purpose, the purpose shall be stated as “at the request of the individual”]:

This authorization will be enforce and effect until the following date/event, at which time authorization expires

(if left blank, it will expire when records are sent)

I understand that I have the right to revoke this authorization at any time, in writing, by mailing such written notification to the Practice’s Privacy Officer, at Helendale Dermatology & Medical Spa, 500 Helendale Road, Suite 100, Rochester, New York 14609
I understand that a revocation is not effective to the extent that the Helendale Dermatology has taken action in reliance on this authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the law provides the insurer with the right to contest a claim under the policy or to contest the policy itself.
I understand that Helendale Dermatology will not condition my treatment on whether I provide authorization for the requested use or disclosure if to do so would be prohibited by federal or state law. If a reason exists under law for conditioning my treatment on obtaining this authorization, I have been advised of that fact and of the consequences of me refusing to sign this authorization. I understand there is the potential for information used or disclosed pursuant to this authorization to be subject to re-disclosure by the recipient if the recipient is not required by law to protect the privacy of the information. I understand that I will receive a copy of this authorization if signed by me.
I hereby authorize the use or disclosure of my health information as described in this form.

Signature of Patient or Personal Representative

Reset

Date

Name of Patient or Personal Representative

Date

Description of Personal Representative’s Authority

Date

Medical Release HIPAA Form