STANDARD AUTHORIZATION OF USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

Information to be Used or Disclosed
The information covered by this authorization includes:
ALL MEDICAL INFORMATION
ALL BILLING INFORMATION
Please indicate below what information you'd like this authorzation to cover.

 
Persons Authorized to Use or Disclose information
Information listed above will be used or disclosed by:
Wyoming Surgical Associates (Name of person or organization)
 

Right to Terminate or Revoke Authorization
You may revoke or terminate this authorization by submitting a written revocation to our office.  You should contact the HIPAA Compliance Officer to terminate this authorization.
 

Potential for Re-disclosure

Information that is disclosed under this authorization may be re-disclosed by the person or organization to which it is sent.  The privacy of this information may not be protected under the Federal Privacy Rule depending on whom the information is disclosed to.
 
Our practice will not condition treatment, payment, enrollment or eligibility for benefits on whether the individual signs this authorization.

The information covered by thus authorization includes:
 

Name of person or organization

Information covered by this authorization may be disclosed to this person (these persons)

 

Name of person or organization

Information covered by this authorization may be disclosed to this person (these persons)