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Nasseri Clinic of Arthritic and Rheumat

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Nasseri Clinic of Arthritic and Rheumat

Authorization for Release of Protected Health Information to NCARD

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Authorization for Release of Protected Health Information to NCARD

The protected health information being authorized for release to the Nasseri Clinics may include the patient's complete medical history and all associated records pertaining to the services to be rendered at the Nasseri Clinics.

This protected health information may include any or all of the following:

Exclusion of specific information from release of medical records:

Primary Reason for Request of Protected Health Information:

Release of Protected Health Information from

By signing this authorization form, I understand that:

1. I have the right to revoke this authorization at any time. Revocation must be made in writing and presented or mailed to the Nasseri Clinics (see address above).

2. Revocation will not apply to information that has already been disclosed in response to this authorization.

3. Unless otherwise revoked, this authorization will expire one year from the date signed.

4. Any disclosure of information carries with it the potential for unauthorized re-disclosure, and the information may not be protected by federal confidentiality rules.

5. Requests for copies of records are subject to preparation and copying fees in accordance with federal/state regulations.

6. The Nasseri Clinics may not condition your receipt of treatment on your signing of this Authorization.

Authorizing Party: I hereby authorize the release of the PHI listed above to the Nasseri Clinics from the medical records.

Use your mouse or finger to sign in the box below.

If Authorizing Party is other than patient, please complete the following:

Patient is unable to sign due to:

Use your mouse or finger to sign in the box below.

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