Patient First Name

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Patient Last Name

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Date of Birth:

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Please list the Kemet Health staff you wish to give authorization to:

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What are they authorized to do?

Obtain Information From Person Listed Below

Disclose To the Person Listed Below

Name(s) + Title(s):

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Full Address:

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Name of Organization / Relation (spouse, family, friend, peer):

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Phone:

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Fax:

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Reason for Release:

Continuing Care / Medical Facility

Billing / Insurance

Legal or Court-Related

Personal Use

Other:

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Please select one

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Are there any limitations on Release (if any)?

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I Understand, as the person signing this authorization:

This Release. I understand that I am giving permission to the provider named above to obtain and/or disclose my confidential healthcare information. I understand that this authorization is effective for a period of 1 year from the date of signature, unless specified.

If applicable, specify other expiration date/event here:

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Right to Refuse: I understand that Kemet Health will not condition my treatment on whether I give authorization for the requested disclosure. However, it has been explained to me that failure to sign this authorization may have the following consequences:

Right to Revoke: I have a right to revoke this authorization, at any time, by sending written notification to Kemet Health. I further understand that once the information is disclosed, Kemet Health is not responsible for redisclosure.

Form of Disclosure: Unless requested specifically in writing for a certain format, Kemet Health reserves the right to disclose information as permitted by this authorization in any manner that we deem appropriate and consistent with applicable law, including but not limited to, verbally, in paper format, or electronically.

I will be given a copy of this authorization for my records and the original will be included in the healthcare record.

Please let parent, guardian, or your personal representative sign below:

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Relationship to Patient

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Date:

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Release of Information

What are they authorized to do?

Reason for Release:

I Understand, as the person signing this authorization:

I Understand, as the person signing this authorization:

I will be given a copy of this authorization for my records and the original will be included in the healthcare record.

Please let parent, guardian, or your personal representative sign below: