I authorize my physician and  clinical staff to use my clinical health records in my treatment. These records are allowed by me to be seen by other physicians, insurance providers , medical billers.

The protected health information is being used or disclosed for the following purposes: Treatment, Billing , Research, Administrative and Pharmaceutical, Therapeutically, Legally as needed.

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This authorization shall be in force and effect until ----------------------- at which time this authorization to use or disclose this protected health information expires.

I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the practice’s =

I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

My physician will not condition my treatment, payment, enrollment in a health plan or eligibility for benefits (if applicable) on whether I provide authorization for the requested use or disclosure except (1) if my treatment is related to research, or (2) health care services are provided to me solely for the purpose of creating protected health information for disclosure to a third party.

The use or disclosure requested under this authorization will result in direct or indirect remuneration to my physician from a third party. 

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Signature of Patient or Personal Representative

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Date written

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Print Name of Patient 

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