Aloha Nui Family Practice, LLC
Authorization to use and disclose Protected Health Information(PHI)
*Please also print and complete New Client & Service Agreement forms.
You have the right to receive a completed copy of
this form. Photocopy/fax copy may be used as original.
Note to client: A fee may apply to this request for records.
Client (Patient) Information:
Name: (Last) _____________________________ (First)
___________________________ (MI) _____
AKA: ___________________________________________________________
Home Phone#: (
) ___________________ Mobile
Phone#: ( )
_________________________
SSN: _______ - _____ - ___________
DOB: (Month) _____ / (Day) _____ / (Year) ________
I, the undersigned, hereby authorize the disclosure, exchange and request of the following Protected Health Information(PHI):
PHI from:
Facility/Individual Name:
__________________________________________________________________
Street Address:
__________________________________________________________________________
City, State, ZIP code:
_____________________________________________________________________
Disclose PHI to: Aloha Nui
Family Practice, 391 Kilauea Ave, Hilo, HI 96720
808.961.1400(office), 808.961.1300(fax)
Note to client: An authorization to disclose PHI is voluntary. Treatment, payment or eligibility for benefits will not be affected if you do not sign this authorization. Redisclosure of a person’s PHI is prohibited without the specific written authorization of that person or as otherwise permitted by state or federal law. Information disclosed pursuant to the authorization may be disclosed by the recipient and no longer protected by Hawaii or federal law.
These medical records are to include all
dates of treatment.
These medical records are to include the dates of treatment from ____________ to ____________.
These medical records are limited to the medical care of my diagnosis of ___________________ only.
(Other) _________________________________________________________________________.
Purpose of the use and disclosure is for the continuity of medical care for the above named client.
Unless otherwise revoked in writing, this
authorization expires on:
As long as a registered client with Aloha Nui Family Practice.
Completion of this request.
Please list all
persons and relationship to who are able to retain your medical
information or make appointments on your behalf.
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*Example: Jane Doe |
Wife |
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Full Name (*please print):
_________________________________________________________
Signature: _______________________________________
Date: ____________________
*Parent or designated guardian name/signature if client is a minor
17 years old or less.
Note to client: You may revoke this authorization
at any time by sending a notice by mail/fax to:
Aloha Nui Family Practice, 391 Kilauea Ave, Hilo,
HI 96720, (fax) 808.961.1300.
