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