Request Appointment Form

I hereby authorize that the protected health information regarding the above named person be forwarded as follows:

MovingInsurance Conflict2nd OpinionTransfer of CarePrimary Physician

I understand that I have the right to inspect and copy the information I have authorized to be disclosed by this authorization. In the event I refuse to authorize the release of the above described information, I understand that it will not be disclosed, except as provided by law. I understand that the practice may not condition treatment on whether I sign this authorization, except when the provision of health care is solely for the purpose of creating protected health information for disclosure to a
third party.
I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by law. I understand that I may revoke this authorization at any time be giving written notice to the physician of my desire to do so. I also understand that I will not be able to revoke this authorization in cases where the physician has already relied on it to use or disclose my health information. Written revocation must be sent to the physician's office. Absent such written revocation, this Authorization for Release if Confidential Health Information will terminate

I understand that there will be a fee charge to me to cover the cost of copying and sending my records.

If you are not the patient, please specify your relationship to the patient: