Transcription of INDIVIDUAL PATIENT’S AUTHORIZATION …
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INDIVIDUAL PATIENT’S AUTHORIZATION …
INDIVIDUAL PATIENT S AUTHORIZATION endocrinology and diabetes Associates, 201 Sivley Road, Suite 450 Huntsville, AL 35801 256-551-4505 Name:_____ Date of Birth: _____ I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that, if the persons or organizations I authorize to receive and/or use the protected health information described below are not health plans, health care providers or health care clearinghouses subject to federal health information privacy laws, they may further disclose the protected health information and it may no longer be protected by federal health information policy laws. I understand that this information serves as: A basis for planning my care and treatment. A means of communication among the many healthcare professionals who contribute to my care.
INDIVIDUAL PATIENT’S AUTHORIZATION Endocrinology and Diabetes Associates, L.L.C. 201 Sivley Road, Suite 450 Huntsville, AL 35801 256-551-4505
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