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
Information to be Used or Disclosed
The information covered by this authorization includes:
Purpose of the Disclosure:
Will this information be used for marketing?
- Yes
- No
Has this information been previously de-identified?
- Yes
- No
Persons Authorized to Use or Disclose the Above Information:
(Name of person or organization)
Persons to Whom Information May Be Disclosed:
(Name of person or organization)
Expiration Date of Authorization
This authorization is effective through
Date Format: MM slash DD slash YYYY

(pick one)
- NO Expiration, unless revoked or terminated by the patient or the patient’s personal representative.
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.
Name of patient*
First Last
Date of Birth
Date Format: MM slash DD slash YYYY
Email*
Phone*
Relationship of Patient Representative to Patient (if applicable)