Designed Health Options Authorization for Release of Information

Name *

First

Last

Date of Birth

Information to be released

Summary of treatment to date
Report
Other

If "Other" above, please describe information

Purpose of Disclosure

Coordination of Care
Other

If "Other" above, please describe purpose of Disclosure

Persons authorized to make Disclosure:

Persons authorized to receive Disclosure: *

Method of Disclosure

Written
Verbal
Electronic

Today's Date:

Authorization to expire on:

I understand that my health information is protected by law. I authorize the release of my confidential health information as indicated above. I understand that my consent is voluntary and I can revoke this permission at any time, except to the extent that it has already been shared based on this authorization. Should I choose to revoke this authorization I will state this in writing. Please Initial Below *

Please initial above, this form will be printed for your signature

Signature of Personal Representative (this form to be printed out for signature, please initial digitally)

Please initial above, this form will be printed for your signature

Once you’ve completed this form click submit, we will receive it and have it printed out and ready for your signature in-person. Thank you.

Designed Health Options, LLC

Click on the Health Condition or Treatment of your Interest

Calls, questions and appointments are welcomed. We’re in Corrales, 8 minutes North of Albuquerque toward Rio Rancho

Click To Call or 505-404-8154