PATIENT AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

My Rights: 

  • I may refuse to sign this authorization. My refusal will not affect my ability to obtain treatment.

  • The recipient may not lawfully further use or disclose the health information unless another authorization is obtained from me, or unless the use or disclosure is specifically permitted by law.

  • I reserve the right to withdraw or revoke this authorization, in writing, at any time, except to the extent that Dr. Levoy has already disclosed the information.

  • I have a right to receive a copy of this authorization.

Patient's Name *
Patient's Name
Date of Birth *
Date of Birth
Phone Number
Phone Number
I hereby authorize Dr. Sarah Levoy to:
Mailing Address
Mailing Address
Recipient Phone Number
Recipient Phone Number
The specified recipient may use the health information authorized on this form solely for the following purpose(s):
Expiration
Expiration
This authorization becomes effective immediately and shall expire on:
Date
Date