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Patient Authorization Release Of Health Information From Another Entity

In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I agree and authorize for the entities listed below to release medical and/or psychological information and records pertaining to my care. I understand that it is my responsibility to notify listed entities if I no longer consent for records to be released or available to Blue Moon Senior Counseling and any of it's affiliates/subsidiaries. I consent to the following entities/providers to release and provide information to Blue Moon Senior Counseling any of it's affiliates/subsidiaries to assist with and inform my care.

Name / Entity	Relationship	Phone / Fax

I authorize this information to be disclosed in the following ways:

Written/photocopy/paper

Verbal

Fax

Specific description of the Protected Health Information that I authorize for disclosure:

Progress Notes

Entire Health Record (Including but not limited to information regarding medical/health treatment, insurance, demographics, referral documents, etc)

Treatment Progress

I give specific authorization for the following to request disclosures of my health information:

At the request of the individual (patient)

At the request of Other: (List names/Relationships)

This authorization is valid, unless a specific expiration date or event is specified here:

I understand I may revoke this authorization at any time in writing. I am entitled to make a copy of, or request to receive a copy of this authorization. I acknowledge by my signature below that I have read and understand this authorization, it accurately reflects my wishes, and a photocopy, facsimile, or other electronic copy is as valid as the signed original.

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Your legal name

Your email address

Please Confirm full name and signature.

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June 13, 2022 11:18 am PDT

Patient Authorization Release Of Health Information From Another Entity Uploaded by Melanie Donohue - new@bluemoonseniorcounseling.com IP 172.250.158.178