Patient Information Form

Authorization for Release of Information to Family and/or Friends

Allergy, Asthma, and Sinus Center, P.C. is authorized to release protected health information about the above-named patient to the entities named below.

Rights of the Patient

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 in this document by signing a written notification to Allergy, Asthma & Sinus Center, PC. I understand that a revocation is not effective in cases where the information has already been disclosed, but will be effective going forward. I understand that information used or disclosed as a result of this 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 upon signing this authorization.

This Authorization shall be in force and effect until revoked by the patient or representative signing the authorization.