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+1 (929) 370-1248
Fax: 909-323-4151
303 5th Avenue Suite 2009, NY, NY, 10016
[email protected]
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Menu
Home
About Us
Our Services
Forms
HIPPA Release Form
Informed Consent for Treatment
Informed Consent for Telemedicine
Card of File Authorization Form
Practice Policies and Appointment Guideline
Patient Demographic Form
Contact Us
Phone:
+1 (929) 370-1248
Book Now
+1 (929) 370-1248
[email protected]
909-323-4151
Home
About Us
Our Services
Forms
HIPPA Release Form
Informed Consent for Treatment
Informed Consent for Telemedicine
Card of File Authorization Form
Practice Policies and Appointment Guideline
Patient Demographic Form
Contact Us
Menu
Home
About Us
Our Services
Forms
HIPPA Release Form
Informed Consent for Treatment
Informed Consent for Telemedicine
Card of File Authorization Form
Practice Policies and Appointment Guideline
Patient Demographic Form
Contact Us
Book now
+1 (929) 370-1248
303 5th Avenue Suite 2009, NY, NY, 10016
[email protected]
Fax:909-323-4151
Book now
HIPPA Release Form
Jonathan Tamaiev MD
Psychiatrist
Jonathan Tamaiev MD P.L.L.C
303 5th Avenue Suite 2009, NY, NY, 10016
+1 (929) 370-1248
HIPPA Release Form
This form, when completed and signed by you, authorizes me to release protected information from your clinical record to the person you designate.
<b>I authorize my psychiatrist, Jonathan Tamaiev MD to release: </b>
<b>This information should only be released to</b>
<b>I am requesting my psychiatrist to release this information for the following reasons:</b>
This authorization shall remain in effect until (fill in expiration date) or until (fill in an event that relates to the individual or the purpose of the use or disclosure).
You have the right to revoke this authorization, in writing, at any time by sending such written notification to my office address. However, your revocation will not be effective to the extent that I have taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
I understand that my psychiatrist generally may not condition psychiatric services upon my signing an authorization unless the psychiatric services are provided to me for the purpose of creating health information for a third party.
I understand that information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient of your information and no longer protected by the HIPAA Privacy Rule.
Full Name
Signature of Patient ((and Patient’s Parent/Legal Guardian if applicable)
Date
MM slash DD slash YYYY
If the authorization is signed by a personal representative of the patient, a description of such representative's authority to act for the patient must be provided.