HIPPA Release of Information

Clymer Healing Center	Woodlands Healing Research Center
5916 Clymer Rd., Quakertown, PA 18951 * 215-536-8001 * Fax 215-536-9099	5724 Clymer Rd., Quakertown, PA 18951 * 215-536-1890 * Fax 215-529-9034

HIPPA Permission for Release of Information

Date: 01/01/2003

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In order to comply with specific rules regarding HIPAA (Health Insurance Portability & Accountability Act of

1996), we ask that our patients complete and sign this privacy and security of health information document.

Patient Name:		Date:
Personal Representative Name:		Relationship:

It is the office policy of Woodlands Healing Research Center not to release confidential and/or unauthorized information by home telephone, answering machine, work telephone, voicemail, or cell phone. Whenever returning telephone calls and the answering machine picks up we cannot leave a message if the name and telephone number is not on the recorded message to identify the residence. Information will also not be left with an unauthorized person who may answer the telephone.

I authorize Woodlands Healing Research Center and staff to leave medical information pertaining to my care by the following methods and will assume responsibility of notifying Woodlands Healing Research Center whenever this information changes.

Patient must sign appropriate release of information before health information will be sent to the following:

Other Physician Office	Yes	No
Insurance Company	Yes	No
Work Telephone, #:	Yes	No

If you would like to have information released to someone other than yourself, please complete the following:

Please list names of people authorized to receive your health information:

Date:

Patient/Guardian Signature:

Click here to Return to New Patient Information Page

Click here to Return to Woodlands Home Page

Home Telephone	Yes	No	Not Applicable
Answering Machine	Yes	No	Not Applicable
Work Telephone, #:	Yes	No	Not Applicable
Voice mail	Yes	No	Not Applicable
Cell Phone/Cell Voicemail, #:	Yes	No	Not Applicable
Work Fax, #:	Yes	No	Not Applicable
Home Fax, #:	Yes	No	Not Applicable
E-Mail, Address:	Yes	No	Not Applicable

Spouse Name:	Yes	No
Mother's Name:	Yes	No
Father's Name:	Yes	No