NeuroRehabilitation & Neuropsychological Services, P.C.

I hearby authorize you to use or disclose the specific information described below, only for the purposes and parties also described below.

Description of the specific information to be used or disclosed:

___________________________________________________________________________

___________________________________________________________________________

Person or entity requesting the information and authorized to make the requested use or disclosure:

___________________________________________________________________________

Recipient of the information: ____________________________________________________

This information is being requested for the following purpose(s):

___________________________________________________________________________

___________________________________________________________________________

This authorization shall remain in effect from the date signed below until

____________________
(expiration date or event)

I understand that:

• I may inspect or copy the protected health information to be used or disclosed.
• I may revoke this authorization in writing by contacting your office at the address above, attention Privacy Officer.
• Information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer be protected by HIPAA.
• I may refuse to sign this authorization and that you will not condition treatment or payment on me providing this authorization (except to the extent that the authorization is for research-related treatment, in which case you may refuse to provide that research-related treatment).

____ If this line is checked, I understand that you will receive compensation from a third party for the use or disclosure of my information.

Patient Name:___________________________Signature:___________________________

Relationship to Patient
(if signed by personal representative of Patient):_________________Date:_____________