PATIENT AUTHORIZATION
TO OBTAIN MEDICAL RECORDS

I authorize Family Practice Associates to OBTAIN my health information FROM:

ATTN:      Medical Records     

Transfer or disclose all my protected health information via Fax or Mail to:

Family Practice Associates
1100 South Broom Street
Wilmington, DE 19805
Fax: 302-485-5032

I understand that as part of my treatment, Family Practice Associates has requested my medical records from the physicians, specialist or organization specified above. I have read this authorization and understand what information will be used for or disclosed, who may use and disclose the information, and the recipient(s) of that information. I understand that when the information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected health information. I further understand that I retain the right to revoke this authorization. Any disclosure of the patient’s protected health information to another address or fax number will require a separate authorization.

The patient has the right to revoke this authorization in writing, except to the extent that action has been taken in reliance on this authorization or, if applicable, during a contestability period. In order for the revocation of this authorization to be effective, Family Practice Associates must receive the revocation in writing. The revocation must include:

• The patient’s name, address, and patient number, if applicable,
• The effective date of this authorization, and the recipients of the protected health information according to this authorization,
• The patient’s desire to revoke this authorization, and
• The date of the revocation, and the patient’s signature.

Family Practice Associates will accept written revocations of this authorization via: Certified U.S. mail or Facsimile. ALL revocations are not effective until received by the Privacy Officer.

This authorization shall expire on 180 days from the date shown below. After this date, my information can no longer be used of disclosed without first obtaining a new authorization form.

I fully understand and accept the terms of this authorization.