D.D.S., M.B.A., MA.Ed.
PT, D.P.T., M.H.S.
M.SC., Ph.D., FAAO
This authorization will expire 1 year from 11/19/2019.
I understand I may withdraw my authorization at any time by submitting a written request to the HIPAA Privacy Officer. I understand any revocation is not effective to the extent action has already been taken in reliance on this authorization. I understand information used or disclosed pursuant to this authorization may be subject to re-disclosure and may no longer be protected by federal or state law. This authorization is not intended to affect a patient's ability to receive medical care.
Alcohol and Drug Abuse Treatment.
To the extent my medical record contains information regarding alcohol or drug treatment that is protected by federal law, I authorize the disclosure of such information or record.
HIV / AIDS Information
To the extent my medical record contains information regarding my HIV/AIDS status, treatment or testing, I authorize the disclosure of such information or record.
Behavioral Health Notes / Record
I authorize the disclosure of any behavioral health notes or information in my medical record.
With my digital signature below, I consent to the release of the above listed information / documents.
Midwestern will contact the patient to schedule an appointment within 48 business hours of receipt.
Patient was informed and understands the following information regarding this referral: