Consent to Release Information

Your name(Required)

First Last

Date of Birth(Required)

Authorize(Required)

Name, address phone of person/ agency SENDING information

To disclose to:

Winooski Integrative Medicine PC
321 Main St. Suite B, Winooski VT, 05404
Do Not Mail Records
Fax records to: 833-464-3117

The purpose of the disclosure is for:(Required)

Transfer Care

Consultation

Other

If other

Medical Information to Disclose. Please check all information you would like to have shared.(Required)

If other

Time period or other specifics related to the information to be disclosed

Enter Starting and Ending Date

All past, present, and future periods

Or enter the date of the document signature until the following event:

You are authorizing Winooski Integrative Medicine to disclose your records in the following formats: written, verbal, electronic, unless otherwise specified here:

I understand that information released may include information related to (check all that apply):(Required)

Medical

Psychiatric/ Mental Health

Hepatitis

Sexually Transmitted Diseases

HIV and AIDS

Genetic Testing

Treatment of Alcohol or Drug Abuse

I understand that my alcohol and/or drug treatment records are protected under the Federal regulations governing Confidentiality and Drug Abuse Patient Records 42 C.F.R. Part 2 and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) 45 C.F.R. Parts 160 and 164, unless otherwise provided for by the regulations.

I also understand that I may revoke this consent at any time by notifying us in writing of my desire to do so except to the extent that action has been taken in reliance on it before I revoked it.

A photocopy or facsimile of this consent is as valid as the original.

I understand there are limited circumstance where I may be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations.

Date or event upon which this consent will expire

I understand if I do not state a date or event, then this consent will expire one year from the last date of service to me at Winooski Integrative Medicine PC.

Your signature on this authorization indicates that you understand the information disclosed under this authorization form and may be re-disclosed by the receiving person(s) or facility and would then no longer be protected by federal privacy regulations.

I waive my right to review my medical records before they are released.(Required)

Yes

Email Address(Required)

Signature(Required)

Date(Required)

Legal Representative Printed Name(Required)

Legal representative name is required for patients under 18 years of age.

Legal Representative relationship

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Patient Information