Release of Information The form is to allow Amber Wellness Group to disclose protected health information to to a guardian, spouse or family member. Patient Name(Required) Email(Required) Date of Birth(Required) MM slash DD slash YYYY I authorize the following practice/physician to disclose my protected health information as indicated below. I also authorize communication between the person, provider or facility indicated below to provide continuity of care.Name of the person(Required) Address Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone(Required)Email(Required) Relationship to Patient(Required) I agree to grant them portal access to(Please select one) Medical Records and Billing Information Billing Information ONLY Consent(Required) By initialing here, I understand that the information in my health records may include information indicating the presence of a communicable or venereal disease which may include, but is not limited to, hepatitis, syphilis, gonorrhea, HIV and AIDS. The records may also include information about behavioral and/or mental health services and/or treatments for alcohol and/or drug abuse.I understand the following: - I may revoke this authorization at any time by providing written notice to Amber Wellness Group - I may not be able to revoke authorization if our practice has already taken action utilizing the authorization or if it was obtained as a condition of obtaining insurance coverage. - Amber Wellness Group will not condition treatment or payment based on my signing this authorization - I am signing this authorization freely without pressureSignature(Required)Date(Required) MM slash DD slash YYYY
