AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION
Completion of this document authorizes the disclosure and/or use of health information, about you.
I request and authorize:
Michael K. Lloyd, M.D. Inc.
460 Greenfield Ave. #3 Hanford, CA 93230
This request & authorization applies to:
• I may refuse to sign this authorization. My refusal will not affect my ability to obtain treatment or payment or
eligibility for benefits.
• I may inspect or obtain a copy of the health information that I am being asked to allow the use or disclosure of.
• I may revoke this authorization at any time, but I must do so in writing and submit it to the following address:
Michael K. Lloyd, M.D., 460 Greenfield Ave. Ste #3, Hanford, CA 93230
• My revocation will take effect upon receipt, except to the extent that others have acted in reliance upon this
• I have a right to and will receive a copy of this authorization.
• Information disclosed pursuant to this authorization could be re-disclosed by the recipient. Such re-disclosure is in
some cases not protected by California law and may no longer be protected by Federal confidentiality law (HIPAA).
Signature of Patient or Patient Representative / Responsible Party
(This authorization will expire in 6 months unless otherwise indicated)
By clicking Accept & Sign I understand and agree that this is a legal representation of my signature.