Authorization for Release of Information

How can MDBI talk to or relay information to YOU? I agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.

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Patient Name *
Date of Birth *
MM
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I understand that Midwest Dizziness and Balance Institute (the“Practice”) has certain rights and obligations regarding my protected health information. I also understand that I have certain rights about my protected health information.

PLEASE FILL OUT THE FOLLOWING STATEMENTS:
Patient Phone #: *
I authorize the Practice to provide verbal reminders via live communication or through voicemail regarding upcoming appointments I may have, to me or anyone who may answer any phone numbers I have provided to the Practice. *
Required
I authorize the Practice to leave voicemails on the phone to relay information regarding my health information, my test results, or any financial information on any phone numbers I have provided to the Practice
 *
Required
I authorize the Practice to relay written information via text on any phone numbers I have provided to the Practice.
 *
Required
Patient Email: *
I authorize the Practice to relay written information via email regarding my appointments, financial documents, estimates, results and following any correspondence I initiate with the Practice. I acknowledge that this form of communication may not be secure.
 *
Required
WHO DO YOU AUTHORIZE MDBI TO TALK TO REGARDING YOUR HEALTH CARE? (IE: spouse, mother, child)
I authorize the Practice to disclose my protected health information to any of the following persons (state name and relationship):
Authorized Persons Name:
 *
Relationship: *
Phone Number: *
Authorized Persons Name:
Relationship:
Clear selection
Phone Number:
WHO DO YOU AUTHORIZE MDBI TO RELEASE YOUR HEALTH INFORMATION TO? (Doctors, Attorneys, Workers Compensation)
I authorize the Practice to disclose my protected health information to any of the following individuals, organizations, or doctor's offices (Name, Phone, Fax, Address):
Authorized Persons Name (ie: Primary Care Dr, ENT, Neurologist). Please put their name, phone and fax number below. If none - type n/a.
 *
Authorized Persons Name (ie: Primary Care Dr, ENT, Neurologist). Please put their name, phone and fax number below
Authorized Persons Name (ie: Primary Care Dr, ENT, Neurologist). Please put their name, phone and fax number below
I understand that I have the right to revoke any authorization granted above by written notice signed by me delivered to the Practice’s Privacy Official at the address stated below. My authorization remains valid until revoked by me in writing. I understand the the revocation will NOT apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest. I understand that once the above information is disclosed, it may be redisclosed by the recipient and the information may not be protected by federal privacy laws or regulation. I understand that authorizing the use of disclosure of the information identified above is voluntary. I acknowledge that the Practice’s Privacy Practices Notice effective April 1 , 2020 regarding the Practice’s rights and obligations and my rights regarding my Protected Health Information is available to me at any time I request. I acknowledge that I understand that I have the right to request and receive clarifications, explanations, or further information regarding The Practice’s Privacy Practices through written request signed by me addressed to the Practice’s Privacy Official. 

Midwest Dizziness and Balance
Institute Attn: Jaime Carmody
12380 Olive Blvd
Creve Coeur, MO 63141

Electronic Signature of Patient/Patient Representative:
 *
Date: *
MM
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DD
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YYYY
Relationship to patient: *
Required
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