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Elite DNA Therapy Services, Authorization to Release Protected Health Information (PHI) Patient Name: Birth Date: Last 4 digits of S.S. # Address: Phone # I request and authorize Elite DNA Therapy

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How to fill out authorization to release protected

01

Step 1: Start by writing your full name and contact information at the top of the form

02

Step 2: Provide specific details about the protected information you are authorizing to be released

03

Step 3: Clearly identify the person or organization you are authorizing to release the protected information

04

Step 4: Specify the scope and duration of the authorization

05

Step 5: Sign and date the authorization form

06

Step 6: Keep a copy of the completed authorization form for your records

Who needs authorization to release protected?

01

Anyone who wishes to authorize the release of protected information

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