Release/Authorization of Disclosure of Health Information

*First Name

*Last Name

Today's Date

*Date of Birth

*Cell Phone

*Email Address

Home Address

City

State

Zip Code

Release of Information From (Sender):

*Your Primary Viverant Location Choose... Minnetonka Edina Eagan St. Louis Park St. Paul Lakeville AF Clubs (Farmington Eagan Lakeville) Vadnais Heights Duluth Woodbury Champlin Nutrition

Relase of Information To (Recipient):

*Recipient Name

Recipient Address

*Recipient Email

*Recipient Contact Number

Disclosure of Medical/Billing Information is limited to the Following (check all that apply)*:

Treatment NotesBilling Details

Approved Method of Delivery

FaxEmailOther

*Approved Method of Delivery Details

This information is to be released for the purpose of (check all that apply):

Patients' RequestInsurance ApplicationMarketing
Review of Current CareLegalSocial Security Disability Determination
Continued CarePaymentOther

Other purpose for information release (if specified)

I understand by signing this form that I am requesting information to be sent/released to the third party I have indicated above. I understand I may revoke this authorization at any time with written notification. I realize that Viverant cannot prevent re-disclosure of records as a result of this request; therefore, Viverant is released from any and all liability resulting from re-disclosure. I have read and understand my rights.

Authorization expiration date

(expires one year from date above unless earlier date indicated)