Medical Release To NFI

MEDICAL RECORD RELEASE ARI AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION (PHI)

This authorization is per Federal Privacy Laws
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
I, the above identified person, do hereby authorize release of my PHI as indicated - Identify individual/group/entity and list address.

To: Nevada Fertility Institute

8530 West Sunset Road, Suite 310

Las Vegas, Nevada 89113

P: (702) 936-8710 F: (702) 936-8711
From: *

Practice NameDoctor Name
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Fax Number (if applicable)
Please provide if we need to fax
I understand that this authorization is voluntary and that it may include information relating to AIDS, HIV infection, behavioral health services/psychiatric care, and treatment for alcohol and/or drug abuse. I understand that if the person/entity that receives my Protected Health Information is not covered by Federal Privacy regulations, the PHI described below may be re-disclosed by such person or entity. I understand that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment or payment or my eligibility for benefits unless the treatment is for research purposes or unless the provision of treatment is related solely to the disclosure of my PHI to a third party such as when requested by my employer.
This authorization covers the following periods of healthcare:
All periods of Healthcare
- or -
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Protected Health Information (PHI) to be used or disclosed:

Entire Medical Record (does NOT include radiology images, billing records and psychotherapy notes)
Check box or boxes:

Office VisitsRadiology ImagesPhychotherapy NotesConsultation ReportsLaboratory ReportsBilling Records (itemized statements, EOB, HCFA1500)Radiology ReportsOperative ReportsOther (please specify below)
This information is being disclosed for the following purposes:
Check box or boxes:

Legal ReasonsAt the Request of the PatientPersonal UseContinued Care and TreatmentInsuranceDisabilityObstetrical CareWorker's CompensationOther (please specify below)
I understand that I/my legal representative may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on this authorization or per law. Written revocation must be sent to the person that I authorized to release my information.
This authorization will expire in 120 days unless otherwise specified (date or specific event):
I hereby certify that I have read the provisions set forth in this authorization. I understand and agree to its terms.
Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
PLEASE ALLOW 5-7 BUSINESS DAYS FOR PROCESSING OF MEDICAL RECORDS
Request Type
JotForm Submitted
Should be Empty:

MEDICAL RECORD RELEASE ARI AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION (PHI)

This authorization covers the following periods of healthcare:

- or -

Protected Health Information (PHI) to be used or disclosed:

PLEASE ALLOW 5-7 BUSINESS DAYS FOR PROCESSING OF MEDICAL RECORDS