Tel: (719) 595-7600
3676 Parker Blvd., Suite 165
Pueblo,CO 81008
 
Fax:(719) 595-7661

AUTHORIZATION TO DISCLOSE PHI TO INDIVIDUALS INVOLVED IN TREATMENT OR PAYMENT


I authorize Park West Imaging (it's employees and staff) to disclose to the following individuals my protected health information as may be necessary for purposes of notifying or otherwise communicating with them regarding my care/ treatment or payment for that care.

I understand that if anyone who receives my health information is not a health care provider or a health plan, my health information may not be protected by federal privacy laws.

I understand this authorization is valid until it is revoked by me, in writing, at any time.
  
Patient Name:
  
Individuals to whom my PHI may be disclosed:
Name of Individual
Address
City, State
Phone Number
Name of Individual
Address
City, State
Phone Number
Name of Individual
Address
City, State
Phone Number
Name of Individual
Address
City, State
Phone Number