CANZ03 PHI

Protected Health Information Access Request Form

Patient Name*

First NameMiddle NameLast Name

Date of Birth*

Date

I grant permission for my healthcare provider and staff members of Cantera Psychiatry to discuss my care using this disclosure form to share relevant information about my healthcare and/or discuss financial information within my account.

I authorize the release of my protected health information to the following person(s)/entity:

	Name	Phone	Relationship
1.
2.
3.

The information you may release subject to this authorization is the following:

Appointment date/time

YesNo

Explanation of Diagnosis/Treatment Plan

YesNo

Lab Reports

YesNo

Billing Information

YesNo

Check here if

I do not want any of my information shared

I understand that my healthcare information at Cantera Psychiatry is protected. By signing this form, I am granting Cantera Psychiatry authorization to disclose my protected health information to the listed individual(s) for the purpose of treatment, payment and health care options. I understand this form will be in effect until I submit an updated copy.

Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Patient/Guardian Signature*

Date*

Date