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) AF Clubs (Inver Grove Heights) Vadnais Heights Duluth Woodbury Champlin Nutrition Chanhassen

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)