Often, it is useful and necessary to obtain information from other healthcare providers who have evaluated or treated you in the past. Additionally, sharing clinical information with other providers currently involved in your treatment can be essential to the coordination of care.
We use the form below to obtain your permission to exchange or receive information from other healthcare providers, from medical facilities, and from other institutions that maintain confidential records of your protected health information. Your provider may ask you to execute this form, after they have completed the fields that pertain to the type of information to be requested. Obviously, your provider will address whatever questions you may have about the privacy of your protected health information.
To fill out this form online, click the Download link on the left. When you are finished with the portion that you can complete online, print it, and complete the circled items by hand.