Auth To Disclose Information | Northwest Rheumatology Specialists

P A T I E N T R I G H T S

The patient has a right to confidentiality of their personally identifiable health information. They also have a right to share their personal health information. They may extend this privilege to a family member or other designated person by a written authorization that will be kept on file by Northwest Rheumatology Specialists. This agreement shall remain in effect until revoked by the patient or their power of attorney (POA).

Patient’s Name:

DOB:

Phone #:

Address:

City:

State:

Zip:

Information to be share:

Laboratory results

X-Ray Results

Examination results

Prescription Drug Information

Plan of Care

Demographic information; including address, birth date, phone, social security number, etc.

All the above

Other:

I understand that my signature will allow physician/staff members of Northwest Rheumatology Specialists to provide the above information to another person authorized by me. I authorize the release of the above information to:

Name of authorized individual:

Telephone number of Authorized Individual:

Relationship to Patient:

Address:

I authorize the release of my personal health information as indicated on this form to the individual identified above. This authorization is good until revoked by myself or my POA.

Signature of Patient:

Date:

Witness:

Date: