RD Finders and Personal Training

Authorization Form
For Uses and Disclosures of Patient Health Information
Name:_______________________________________________
Date of Birth: ________________________
I hereby authorize RD Finders and Personal Training to release the
protected health information indicated below to:

Name:________________________________________________________
Phone Number: ________________________________________________
Address: ______________________________________________________

Requested Information:
I authorize the disclosure of the following types of records created from
______________ to ______________:
Note:You will be charged $.25 per page for paper records and $5.00 per
film for radiology films.
[ ] Billing Records[ ] Lab Reports [ ] Pathology Reports[ ] Radiology
Reports [ ] X-rays[ ] Other________________________________________
[ ] Information created or received from other providers. (Specify which
ones or “all”) __________________________________________________
[ ] Entire designated record set
Purpose of the Requested Use or Disclosure:
The purpose of the use or disclosure is:
[ ] At the request of the patient or
[ ] Other (indicate specific reason)__________________________________
Expiration Date

This authorization will automatically expire:

[ ] _________________ (May not exceed 12 months from the date of the
signature below.) or
[ ] When the following event occurs:
____________________________________________________________

Signature: ____________________________________________________
Date: ________________________________________________________

2400 Jordan St. * Dallas, TX 75215 * 214-280-7474 * Fax 214-421-3835