Standard Authorization of Use and Disclosure of PHI

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    Wyoming Surgical Associates, P.C
    Ph: 307-577-4220, Fax: 307-235-0931
    419 S. Washington, St. Ste. #200 Casper, Wy 82601

  • The information covered by this authorization includes:
  • (Name of person or organization)
  • (Name of person or organization)
  • Expiration Date of Authorization
  • Date Format: MM slash DD slash YYYY
    (pick one)

  • Right to Terminate or Revoke Authorization
    You may revoke or terminate this authorization by submitting a written revocation to our office. You should contact the HIPAA Compliance Officer to terminate this authorization.
    Potential for Re-disclosure
    Information that is disclosed under this authorization may be re-disclosed by the person or organization to which it is sent. The privacy of this information may not be protected under the Federal Privacy Rule depending on whom the information is disclosed to.

    Our practice will not condition treatment, payment, enrollment or eligibility for benefits on whether the individual signs this authorization.
  • Date Format: MM slash DD slash YYYY