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Compound Authorization for Release of Information

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Family Medicine of SayeBrook, LLC is authorized to release protected health information about the above-named patient to the entities named below. The purpose is to inform the patient or others in keeping with the patient’s instructions.

Person authorized to receive Protected Health Information about you: Please check each person/entity that you approve to receive information.

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I authorize Family Medicine of SayeBrook, to contact me by text message regarding appointment and prescription refill information. I understand that SMS messages may be subject to carrier fees and are patient responsibility.
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I authorize Family Medicine of SayeBrook to access my medical and prescription history and for that information to be entered into my medical record.
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I give authorization for the release of Protected Health Information by voice, text message or email.
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Authorized to receive information regarding:

Rights of the Patient

For email and/or text communication, I understand that if information is not sent in an encrypted (secure) manner, there is a risk it could be access inappropriately. I still elect to receive email and/or text communication as selected.

I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copy the Protected Health Information to be disclosed as described in the document. I understand that a revocation is not effective in cases where the information has already bee disclosed but will be effective going forward.

I understand that information used or disclosed as a result of the authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.

I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. This authorization shall be in effect until revoked by the patient.

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Signature of Patient or Personal Representative

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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Necessary documentation to be kept on file.