LONDONDERRY GASTROENTEROLOGY ASSOCIATES
DR. MARK DETWEILER
44 Birch Street, Suite 206
Derry, NH 03038
Phone: (603) 818-4712 Fax (603) 260-6937
AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION
_________________________________________________ ________________
Patients Full Name
Date of Birth
____________________________
Social Security Number
Address
I authorize Londonderry Gastroenterology Associates to:
___Send/Disclose information to
___Receive Information from
___Discuss with
Name:__________________________________________________________ Phone:_____________________________
Address:________________________________________________________ Fax: ______________________________
______________________________________________________________________________________________
For the following purpose(s): ___Provider Transfer ___Primary Care ___Legal/Attorney ___Coordination of Care
Type of Information Requested:
___ Office/Progress Notes
___ Inpatient/ER Notes
___Labs and Tests
Dates of Care to be released: _________________________________ to _____________________________________
I understand that:

A fee for the cost of processing this request may be charged. At your request we will provide you with a copy of
this form.

I understand that my healthcare will not be affected if I do not sign this form.

I hereby authorize Londonderry Gastroenterology Associates to use/disclose my individually identifiable health
information as described below (which may include photographs and/or information concerning treatment for
drug/alcohol abuse and/or treatment, mental health, HIV/AIDS, sexually transmitted diseases, or genetic testing, if
applicable).

I understand that if the recipient authorized to receive the information is not a covered entity, such as insurance
company or health care provider, the disclosed information may no longer be protected by federal and state
privacy regulations and may be re-disclosed.

Londonderry Gastroenterology Associates may utilize a trusted business associate/authorized agent to assist in
fulfilling this request.

I can revoke this authorization at any time by submitting a request in writing to Londonderry Gastroenterology
Associates.

This authorization expires one year from the date of signature, or on ________________________________.
________________________________________________________
Signature of Patient, Parent, or Legal Guardian
____________________________________________________
Print name of Patient, Parent, or Legal Guardian
___________________________
Date
_____________________________________________
Authority or Relationship of Representative
(attach copy of documentation of authority for guardian)
Revised Sept. 2014