EmailMe Form - Authorization to Disclose PHI

Patient Name: *

First Last

Date of Birth: *

MM / DD / YYYY

I, the undersigned, hereby authorize my medical provider (listed below): *

To disclose my personal health information TO and FROM Lifestyle Medical Centers

To disclose my personal health information TO Lifestyle Medical Centers

To disclose my personal health information FROM Lifestyle Medical Centers

Name of Medical Practice/Facility: *

Name of Doctor/NP/PA: *

First Last

Address of Medical Practice:

Street Address City State / Province / Region Postal / Zip Code

Phone:

Fax:

Insert today's date: *

MM / DD / YYYY

This consent will expire on MM/DD/YYY (Insert future date, i.e. one year from today's date): *

MM / DD / YYYY

Signature of Patient (type your name):

Draw your Signature *

Clear

This authorization shall cover LifeStyle Medical Center and all of their respective employees, workforce, and business associates.

This authorization may be revoked at any time, provided that the revocation is executed in writing to the LifeStyle Medical Center Chief Compliance Officer at 10208 Cerny St, STE 301, Raleigh, NC 27617. Revocation will not affect any disclosures acting upon by the disclosure and prior to request for revocation. Information disclosed pursuant to this authorization may be re-disclosed and is no longer protected by federal and state privacy rules. Authorization of disclosure of the above information is voluntary and this authorization is not intended to alter the patient's ability to receive medical care from any health care provider.