Authorization for Release of Information I voluntarily authorize the use or disclosure of my individually identifiable health information as described below.NameFirstLastEmailDate of Birth Persons/organizations providing the information:Person/organizations receiving the information:Specific description of information (including date(s)):This information is being disclosed for the following purposes: (e.g., relocation to another state, following medical care elsewhere, insurance purposes or disability purposes)Expiration date - Please enter date 1 year from today If this is not completed the request will expire after forwarding the personal health information to the above requested party.I may revoke this authorization at any time by notifying the practice in writing to: Denver Nephrology 130 Rampart Way, #300B Denver, CO, 80230 If I do revoke my authorization, any information previously disclosed cannot be withdrawn. Once information about me is disclosed in accordance with this authorization, the recipient may re- disclose it and the information may no longer be protected by federal privacy regulations.I may refuse to sign this authorization form. If I choose not to sign this authorization form, this will not affect my treatment.EmailThis field is for validation purposes and should be left unchanged.
