Consent to Release Personal Health Information
- Download the attached file, or Print this page
- Complete the information required, sign and date
- Take a picture with your phone, Scan, Fax and send to our office by email or postal mail (addresses below)
Purpose: Consent for the release of protected health information
Duration: Until withdrawn or benefit plan terminates
Use: Exclusively for treatment, payment or healthcare coordination activities
Restrictions: No acquired information will be released beyond insurers and their business associates.
I, ___________________, consent to allow Pro Health Advisor (PHA), a clinical case management company to view my protected health information (PHI) so as to advise me regarding my health care issues: heart disease, kidney disease, diabetes, metabolic, cancer or nutritional disorders.
Duration: Expiration Date __________________ (one year suggested)
Federal Privacy Rule Disclosure Requirements:
• I can cancel my consent at any time in writing to Pro Health Advisor.
• If I refuse to provide this consent PHA will not refuse to treat me.
• I read the HIPAA disclosure document provided by PHA.
• I can also specifically restrict information about certain diagnoses of HIV, AIDS or mental health.
• If I share information with PHA could, possibly, be further released and unprotected by confidentiality laws due to error or loss.
This information may include all treatments, diagnoses, health care notes and results. The sources of information may include family members, present and past providers and specialists. Any information obtained will be accessible only to need-to-know members of the PHA for the sole purpose of managing treatment and will not be released to any other entity without your express permission.
Requested information usually includes provider office notes and lab/clinical test results from providers or discharge summaries, operative reports, clinical notes, and management notes from hospitals or treatment facilities for the last visit but may include the previous year.
• I consent to this release of information to Pro Health Advisor:
Signed: _______________________________ Date____________ Name: _________________________
DOB, ________, Last 4 digits of Social Security number: _ _ _ _
Pro Health Advisor, A Patient Assistance Program; Dr. Philip Blair, MD; Nancy J. Weber, Registered Dietitian
1880 Auburn Lane 24-H Surfside Beach, SC 29575 fax 888-909-5897 voice 843-839-9088 Info@prohealthadvisor.com