Authorization for Release of Protected Health Information

I authorize Alliance Physical Therapy Partners (Alliance) and affiliated entities to release information from my medical records to the following entity or persons:

Name

Address

City

State

Zip Code

Phone Number

Fax Number

Reason for Request:

Patient RequestLegal ProceedingsAuto/Liability ClaimOther

Please check type of information to be released:

Entire Medical RecordBilling RecordsRecords covering period of time Records for the following body part or condition

I have read and understand the following:

I may revoke this authorization at any time by submitting a written request to the Privacy Officer at compliance@allianceptp.com or by mail at Privacy Officer, 607 Dewey Ave NW, Ste 300, Grand Rapids, MI 49504.

Alliance may disclose or be allowed by law to refuse to permit access or allow disclosure of part of all of my medical record. If that happens, Provider will notify me in writing.

I may refuse to sign this authorization. If I refuse to sign this authorization, my treatment, payment, health plan enrollment, or eligibility benefits will not be affected.

Information released on this authorization, if re-disclosed by the recipient, is no longer protected by Provider.

Alcohol/Drug Abuse	HIV/AIDS Information
Mental Health Diagnosis/Treatment	Domestic Violence Counseling
Sexual Assault Counseling	Genetic Test Information