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DR. GARY J. SCHMIDT, LLC.

Open Authorization to Release Protected Health Information

Patient Name:

___________________________________________________________

Address:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

City:___________________________

State:

_________Zip Code:

__________________

Date of Birth:

___________________

Social Security #:

--

________ ________ ________

I, _______________________________hereby authorize Dr. Gary J. Schmidt, LLC. to release any and all Protected Health Information maintained in my Medical Record to the following individuals, concerning my status as a patient, treatment, or payment of serviced provided by Dr. Gary J. Schmidt.

_____________________________________

________________________

_____________________________________

________________________

_____________________________________

________________________

_____________________________________

________________________

Name

Relationship to Patient

This authorization is given freely with the understanding that:

  • 1.

    This authorization is valid for a period of one year, unless revoked by me.

  • 2)

    I may revoke this authorization at any time, except where information has already been released, by completing Dr. Gary Schmidt, LLC Revocation of Authorization Form.

  • 3)

    Individuals listed on this form will be able to receive any and all Information related to my status as a patient, treatment, or payment of services provided to me by Dr. Gary J. Schmidt, LLC during the time period in which this authorization is valid.

  • 4)

    Individuals not listed above will NOT be able to received any information Regarding treatment or payment for services provided to me without my prior written authorization.

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