Authorization to Disclose Private Health Information

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To: Wyoming Surgical Associates, PC
I hearby authorize your organization to release the following personal health information:*
First Last
*
- ALL MEDICAL INFORMATION
- ALL BILLING INFORMATION
To the following people (list names and relationship)
DURATION:
THIS AUTHORIZATION SHALL BECOME EFFECTIVE IMMEDIATELY AND SHALL REMAIN IN EFFECT UNTIL REVOKED.

Right to Terminate or Revoke Authorization
You may revoke or terminate this authorization by submitting a written revocation to Wyoming Surgical Associates, P.C. You should contact our Compliance Officer to terminate this authorization.

Potential for Re-disclosure
Information that is disclosed under this authorization may be disclosed again by the person or organization to which it is sent. The privacy of this information may not be protected under the federal privacy regulations.
Name*
First Last
Email*
Phone*
Date
Date Format: MM slash DD slash YYYY