Which office are you being treated in?* Toms River Freehold Email* Authorization for Release of Health Information(Required by the Health Insurance Portability and Accountability Act (HIPPA), 45 C.F.R., Parts 160 and 164)Today's Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Patient Name* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201. AUTHORIZATION:I authorize Pathways Neuropsychology Associates to use and disclose the protected health information described below to:Physicians: Attorney: Other: 2. EFFECTIVE PERIOD:This authorization for release of information covers the period of healthcare from: Start DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920toEnd DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920**OR** all past, present & future periods 3. EXTENT OF AUTHORIZATION: I authorize the release of my COMPLETE health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse). **OR** I authorize the release of my complete health record with the EXCEPTION of the following information: Mental Health Records Alcohol/drug abuse treatment Communicable diseases Demographic information Other please specify "Other" if chosen 4. This medical information may be used by the person I authorize to receive this information for medical treatment of consultation, billing or claims payment, or other purposes as I may direct. 5. This authorization shall be in force and effect until the date specified in Section 2. EFFECTIVE PERIOD, at which time this authorization expires. 6. I understand that I have the right to revoke this authorization, in writing, at any time and this authorization will expire when treatment ends. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. 7. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether l sign this authorization. 8. I understand that information used to disclose pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. I understand that my records are protected under HIPAA State Confidentiality Regulations and cannot be disclosed without my written consent or otherwise provided for in the regulations. (If patient is a minor (17 & under), both parents or guardians are required to sign this release. If the minor is 14-17 years of age their signature is also required.)Signature of patient or personal representative*Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Printed Name of patient or personal representative Relationship to patient Signature of minor patient 14-17DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Δ
