NOTE: In the event that the facility is unable to accomodate an electronic delivery as requested, an alternate delivery method will be provided (e.g. paper copy). There is some level of risk that a third party could see your PHI without your consent when receiving encrypted media or email. We are not responsible for unauthorized access to the PHI contained in this format or any risks (e.g. virus) potentially introduced to your computer/device when receiving PHI in electronic format or via email.


  • Protected Health Information can be released to the following individuals/companies:

  • I understand that:
    1. Upon completion of a visit, corroborating medical records are automatically forwarded to the referring physician.
    2. Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization. I can refuse to sign this form, as it is voluntary.
    3. I may revoke this authorization at any time in writing, but if I do, it will not have any effect on actions taken prior to receiving the revocation. Further details can be found in the HIPAA notices.
    4. If the requester or receiver is not a health plan or healthcare provider, the released information may no longer be protected by federal privacy regulations and may be re-disclosed.
    5. Medical records copied for reasons other than continuity of care are subject to a copy fee (NRS 629.061). These include but are not limited to legal requests, investigative agencies, insurance companies, and patient personal use requests. Multiple copies will be charged for.
    6. CHC will take precautions to avoid improper access to PHI but I acknowledge that if I lose the CD and/or password, they are stolen from my possession, or if I allow another person access to the CD/password, CHC will not be liable for any resulting unauthorized access under any circumstances.
    7. I am aware that if medical notes are requested, the mental health notes are not automatically released and are in fact kept separate from all other clinic notes.
    8. This PHI is in fact null and void without the signature or adopted digital signature of the patient (if 18 or older), parent or legal guardian.

  • I have read the above terms and condistions and authorize the disclosure of the protected health information as stated:

  • Typing your name in this field is your legal signature.