Important: Please read this form carefully. Incomplete or unclear forms may delay processing.
Patient Information
(Include suffixes such as Jr., Sr., III and any previous names)
Authorized Representative (Optional)
If there are questions about this authorization, Miles Med Management may contact:
Organization Releasing Information
I authorize Miles Med Management to release my health information as specified below.
Recipient of Information
Please send the requested health information to:
Information to be Released
Please indicate only the information you authorize to be released:
Specially Protected Information (Required Explicit Consent)
Even if you authorize release of all health information above, the following must be specifically approved:
Psychotherapy Notes:
I understand psychotherapy notes are NOT included in this authorization.*
I understand psychotherapy notes require a separate, standalone authorization form and will not be released using this document.*
Method of Disclosure
Purpose of Release (Check all that apply)
Expiration and Revocation
This authorization will expire one (1) year from the date signed unless an earlier date or event is specified here:
I understand that I may revoke this authorization at any time by submitting a written request to Miles Med Management. Revocation will not apply to information already released.*
I understand that information disclosed may be re-disclosed by the recipient and may no longer be protected under federal or state privacy laws.*
Signature
I certify that I am the patient or legally authorized representative and that the information above is accurate.
OR
Miles Med Management
If you have questions regarding this form, please contact Miles Med Management.
