Authorization for Release of Information

  • 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Rampart Way, #300B Denver, CO, 80230 If I do revoke my authorization, any information previously disclosed cannot be withdrawn.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.
  • This field is for validation purposes and should be left unchanged.

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