* Required Information
  • I authorize the use or disclosure of the above-named individual’s health information as described below.
  • The following individual or organization is authorized to make the disclosure:
    (please include full name of physician or organization, address, phone, and FAX number)
  • The type and amount of information to be used or disclosed is as follows, please circle as indicated:
  • I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for drug and alcohol treatment.
  • This information may be disclosed to and used by the following organization for continuity of healthcare:
    Advanced Wellness Services
    Advanced Wellness Services
    100 Enterprise Drive, Suite 301
    Rockaway, New Jersey 07886
    Phone: 973-986-0660
    Fax: 973-281-4848
  • I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the individual or organization previously given permission to disclose my records (named above in item 2). This authorization will expire in three months.
  • I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I will not need to sign this form to assure treatment. I understand I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential or an unauthorized redisclosure and the information may not be protected by federal confidentiality rules.

Clear

Clear

I consent to the collection, use, storage, and processing of my personal and, where applicable, health-related information, including any data I submit on behalf of others, for the purpose of evaluating or fulfilling my request made through this form. I understand this will be handled in accordance with the Privacy Notice.