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Authorization for Use, Disclosure and Release of Health Information Mobile App

This mobile application contains information concerning health information. It covers the basic disclosure information. Then it asks for the the information needed, the reason and informs you of your rights.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Authorization for Use, Disclosure and Release of Health Information Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Student Athlete/Patient Name

  • Ico date

    Date

  • Ico textbox

    Address

  • Ico textbox

    City

  • Ico textbox

    State

  • Ico textbox

    Zip

  • Ico statictext

    I authorize the following persons (or class of persons) to make authorized use and/or disclosure...

  • Ico statictext

    I authorize the following persons (or class of persons) to receive my protected health informati...

  • Ico dropdown

    INFORMATION TO BE RELEASED:

  • Ico dropdown

    In compliance with State and Federal Statutes, which may require special permission to release ot...

  • Ico statictext

    PURPOSE FOR DISCLOSURE: (Check applicable categories)

  • Ico checkbox

    Further Medical Care

  • Ico checkbox

    Legal Investigation or Action

  • Ico checkbox

    Changing Physicians

  • Ico checkbox

    Medical Ability and Fitness to Participate in Athletics

  • Ico checkbox

    Health and Injury Status for Athletics

  • Ico checkbox

    Insurance Eligibility / Benefits

  • Ico checkbox

    Other

  • Ico statictext

    I understand that if the person(s) and/or organization(s) listed above are not health care provid...

  • Ico statictext

    YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION:

  • Ico statictext

    Right to Inspect or Copy the Health Information to be Used or Disclosed- I understand that I hav...

  • Ico statictext

    EXPIRATION DATE: This authorization is good for one year from the date signed.

  • Ico statictext

    I have had an opportunity to review and understand the content of this authorization form.

  • Ico signature

    Student Ath;ete/ Patient Signature

  • Ico date

    Date

  • Ico signature

    Witness Signature

  • Ico textbox

    Witness Print Name

  • ...and More!

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