Release Form

HIPAA Authorization for Release of Information

Privacy Policy Consent*
I hereby state that I have read, the Notice of Protected Health Information Privacy Practices of Susanne Consiglio, RDN and have received a copy for my personal records.
Medical Records Consent*
I give permission to my doctor and request that my most recent medical record information and most recent laboratory data and test results be released to Nutrition Balance LLC/Susanne Consiglio, RDN upon request.
Information Releas Consent*
I hereby authorize Susanne Consiglio, RDN, registered dietitian to release information necessary for the purpose of informing my physician and/or therapist of my treatment disclosures and progress and to secure the payment of benefits.
My Doctor's Name*
My Doctor's Location*
Patient Name*
Date*
MM slash DD slash YYYY
Signature*
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Name
This field is for validation purposes and should be left unchanged.

Susanne Consiglio, RDN, of Nutrition Balance LLC has posted the Notice of Protected Health Information Privacy Practices in her office and is HIPAA Compliant.