This document is an authorization form for Dr. R. Mark Pappas to release a patient's protected health information. It lists the patient's name and address, date of birth, and social security number. It authorizes Dr. Pappas to disclose the patient's medical and financial records to Dr. Pappas' own practice located in West Haven, Connecticut. The patient must sign to acknowledge they understand their rights regarding the authorization and that they are signing freely.

1. Dr. R. Mark Pappas
299 Main Street
West Haven, CT 06516
203-937-7246
AUTHORIZATION TO RELEASE INFOMATION
Patient Name: ____________________________________________________
Patient Address: __________________________________________________
Date of Birth: _________
Other Identifier (Social Security #) ___________
I hereby authorize this practice to make uses and disclosure of my protected
health information (information about me in my medical records and or financial
records as indicated below.
THIS INFORMATION IS TO BE DISCLOSED TO:
Name of Entity:
Dr . Mark Pappas, P.C.
299 Main Street
West Haven, CT 06516
(203) 937-7246 ph
(203) 931-9266 fax
Description of Information to be disclosed: _____________________________
Reason for requested use or disclosure: _______________________________
TO BE READ AND SIGNED BY PATIENT:
I understand the following:
a.
I may revoke this authorization at any time by providing written notice to this practice
b.
I may not be able to revoke this authorization if the practice has already taken action
utilizing this authorization or if the authorization was obtained as a condition of obtaining
insurance coverage
c.
The practice will not condition treatment or payment based on my signing this
authorization
d.
I am signing this authorization freely
e.
No one has pressured me to sign this authorization
f.
The information disclosed in this authorization may be subject to re-disclosure by the
practice and no longer protected by federal law
g.
I acknowledge that I have had an opportunity to review this and understand the intent and
use
h.
I have received a copy of this authorization.
------------------------------------------------------------------------------------------------------------------------------------------Patient Signature: ____________________________________________________ or
Patient Representative: ___________________________
Date: ___/____/____
Relationship: _____________________