Spectra Health Medical ROI 2024

Authorization for Disclosure of Protect Health Information

Patient Demographic Information
Patient Name *

First NameLast Name
Patient Date of Birth *

MonthDayYear
Date
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Maiden/Other Names Used
Patient Phone Number
Please enter a valid phone number.
Patient Email
example@example.com

Your Rights with Respect to this Authorization and Signature Capture
I understand that if the person(s) and/or organization(s) listed above are not health care providers, health plans, or health care clearinhouses, who must follow privacy standards, the health information disclosed as a result of the authorization may no longer be protected by the federal privacy standards and my health infomation my be redisclosed without obtaining my authorization.
YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION:

Right to Inspect or Copy the Health Information to be Used or Disclosed - I understand that I have hte right to inspect or copy the health information I have authorized to be used or disclosed by this authorization form. I may arrange to inspect my health information or obtain copies of my health information by contacting Spectra Health Clinical Records Department at (701) 757-2810.

Right to Receive a Copy of this Authorization - I understand that if I agree to sign this authorization, which I am not required to, I must be provided with a signed copy of the form.

Right to Refuse to Sign this Authorization - I understand that I am under no obligation to sign this form and that the person(s) and/or organization(s) listed above who I am authorizing to use and/or disclose my information may not condition treatment, payment, enrollment in a health plan or eligibility for health care benefits on my decision to sign this authorization.

Right to Withdraw this Authorization - I understand written notification is necessary to cancel this authorization. To obtain information on how to withdraw my authorization or to receive a copy of my withdrawl, I may contact: Spectra Health Clinical Records Department at (701) 757-2810. I am aware that withdrawl will not be effective as to uses and/or disclosures of my health inforamtion that the person(s) and or organization(s) listed above have already made about this authorization.
Expiration Date

MonthDayYear
If an expiration date is not specified, this form will be valid for one year from the date of signature
Signature*

Clear
Today's Date*

MonthDayYear
Date
Relationship to Patient*
If signed by someone other than the patient, state relationship and ability to do so (e.g., parent, legal guardian, power of attorney, etc.), otherwise, state "self".
Should be Empty:

Authorization for Disclosure of Protect Health Information

Disclosure Details and Third Party Information

*Please note that release forms that are marked for mutually exchanging information will be put on file, but no immediate action will be taken to release or obtain records from the third party listed on this form