I hereby voluntarily authorize _____________________________________________________
(physician, medical practitioner, hospice, hospital, clinic or other medical or medically related
facility, insurance support organization, pharmacy, or any other institution or
person) (hereafter, “Authorized Discloser”) to release my individually identifiable,
protected health information as described below to Faenzi Associates, or to its designee,
Kathy C. Faenzi, MA (collectively, “Authorized Recipient”), P.O. Box 1760,
Burlingame, California, 94011-1760; ph: (650) 401-6350; cell: (650) 307-4000; fax:
I hereby authorize the release to Authorized Recipient of my individually
identifiable health information, consisting of my entire health record from all past,
present, and future periods of health care, including all medical and treatment
records related to my physical and mental health, communicable diseases, HIV or
AIDS, and treatment of alcohol or drug abuse.
I further authorize the disclosure to, inspection by, and copying by Authorized Recipient
of any and all records, reports, and other documents, including any underlying data
regarding care and treatment and any other personal health information concerning any
treatment or hospitalization, including, but not limited to, all testing materials completed
by or administered to Authorized Discloser, all medical charts, clinical or doctors’ notes,
memoranda, medical reports, X-ray reports, index cards, history notes, photographs,
records, and medical bills in the possession and control of the Authorized Discloser.
Authorized Recipient may use my individually identifiable health information for
medical treatment or consultation, billing or claims payment, or other purposes as I may
I understand that I have the right to withdraw permission for the release of my
individually identifiable health information, and that if I sign this authorization to use or
disclose my information, I may revoke this authorization at any time. I understand that
such revocation will not affect information that has already been used or disclosed, or any
action already taken in reliance on this authorization, which cannot be reversed. Notice
of revocation may be directed in writing to the Authorized Discloser at the address
designated by Authorized Discloser. If this authorization has not been earlier revoked, it
will automatically terminate one (1) year from the date of my signature.
I understand that I have the right to receive a copy of this authorization.
I am signing this authorization voluntarily. I understand that my treatment, payment,
enrollment or eligibility for benefits will not be affected if I do not sign this authorization.
I understand that information used or disclosed pursuant to this authorization may be
disclosed by the Authorized Recipient and may no longer be protected by federal or state
law, including but not limited to the Health Insurance Portability and Accountability Act
Privacy Rule [45 CFR Part 164].