First Name

Last Name

hereby authorize your organization to release the following personal health information:

ALL MEDICAL INFORMATION

ALL BILLING INFORMATION

to the following people (list name and relationship):

Duration

THIS AUTHORIZATION SHALL BECOME EFFECTIVE IMMEDIATELY AND SHALL REMAIN IN EFFECT UNTIL REVOKED.

Right to Terminate or Revoke Authorization

You may revoke or terminate this authorization by submitting a written revocation to Casper General Surgery. You should contact our office to terminate this authorization.

Potential for Re-Disclosure

Information that is disclosed under this authorization may be disclosed again by the person or organization to which it is sent. The privacy of this information may not be protected under the federal privacy regulations.

Signature of Patient or Guardian