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Release of Information

Patient Name:

Phone:

Date of Birth:

Address: City: State: Zipcode:

Date of Request:

Optimum Health and Wellness Physical Therapy Inc. is authorized to release and receive patient health information as follows:

Information to be used or disclosed:

Entire record including, without limitation, personal health information and other records pertaining to treatment, payment or services sought or received, including non-medical services and the records listed below.

(If the above box is checked, all boxes below are presumed to be checked.)
*See checked boxes below for specific requests.

Admission/Intake Summary Health History/Physical Records Psychosocial History Progress Notes Treatment Plan Medication Records Discharge Summary Educational Assessments Psychological Evaluation Psychiatric Evaluation Other

If Other, please specify:

NOTE: Psychotherapy notes CAN NOT be released with this Authorization form. Provide a separate Psychotherapy Authorization to obtain those records.

Name of Organization(s), person(s), or class of persons authorized to release and receive health information:

Purpose(s) for which health information may be used/disclosed:

At the request of the individual's personal representative.

Other

If Other, please specify:

Authorization Expires On:
*If this is not completed, Authorization expires one year from date of signature.

I understand that I have the right to revoke this authorization, except to the extent that it has already been relied upon or records have already been released. I may revoke this authorization by writing to the provider to whom this was provided.
I understand that information disclosed under this Authorization may be redisclosed by the recipient. The federal privacy rules may not protect my health information once the recipient rediscloses my health information.
I understand that I may decline to sign this authorization. I understand that covered entities may not refuse to treat me or otherwise condition benefits on signing this authorization, except that a provider may refuse to provide me with research-related treatment if I do not authorize use or disclosure of my health information for research purposes. Also, if the purpose of my treatment is solely to disclose health information to a third party, the provider may refuse my treatment if I do not agree to authorize disclosure of my health information to that third party.

Description of Authorized Representative’s authority to act for the patient:
A COPY OF THIS SIGNED AUTHORIZATION MUST BE PROVIDED TO THE PATIENT OR PATIENT REPRESENTATIVE.
NOTE: This completed form will be emailed as a PDF to the email provided.

BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND THAT I UNDERSTAND THIS AUTHORIZATION FORM.

Signature of Client/Patient or Authorized Representative:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

February 13, 2024 3:17 pm AKST

Release of Information Uploaded by Jaimee Watson - jaimee@ohwpt.com IP 206.223.197.206

February 16, 2024 5:03 pm AKST

Annie Morris - annie@ohwpt.com added by Optimum Health and Wellness - stella@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

February 16, 2024 5:03 pm AKST

Stella White - stella@ohwpt.com added by Optimum Health and Wellness - stella@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

February 16, 2024 5:03 pm AKST

Document owner stella@ohwpt.com has handed over this document to jaimee@ohwpt.com 2024-02-16 17:03:25 - 206.223.197.206

February 16, 2024 5:03 pm AKST