Authorization for Release of Protected Healthcare Information

License: 603 261 405

Graham & Graham LLC is an Eldercare Referral Agency

  1. I authorize the disclosure and release of protected health information from any of my health care providers, their employees, and agents. My release authorization includes my complete health record including diagnosis, medical records, status, examination, medications, treatments rendered to me and claims information. This information may be released to:
    1. Any Staff Member/Agent of Graham & Graham Eldercare Consultants
    2. Potential care providers including Home Care/Home Health Providers, Assisted Living Facilities, Memory Care Facilities, Residential Care Homes, Skilled Nursing Facilities, Physicians and Caregivers.
  2. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, selection and placement of care facilities and/or providers, or other purposes.
  3. This authorization for release of information covers the period of healthcare for a period of one year.
  4. This authorization shall be in force for a period of one year until/unless I terminate it in writing prior to one year from the date signed.
  5. I understand that I have the right to revoke this authorization in writing at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization.
  6. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient to others specifically involved in my care planning process.

Acknowledge release of protected healthcare information

Please read this form and carefully fill out the form accurately.
  • Person filling out this form

    Only yourself, or a authorized healthcare representative may fill out this form.
  • Person whose records are to be released

  • Enter the full complete name of the person this release and authorization is intended for.
  • Confirmation of authorization to release healthcare information

    By checking the box below and digitally signing this form you hereby acknowledge your understanding of this electronic form, and authorize the provisions of this document and release.
  • Printing your name here is considered a digital signature for this electronic form. You are authorizing the provisions of this entire electronic form and document.