Authorization for Release of Information – Busch’s Pharmacy

I. Information About the Use or Disclosure

I hereby authorize the use or disclosure of my individually identifiable health information from the Pharmacy as described below. I understand that this authorization is voluntary and that I may revoke it at any time by submitting my revocation in writing to the Pharmacy.

Individual's name: __________________________________

Persons/organizations authorized to receive the information: ______________________
__________________________________________________________________________

Specific description of information to be used or disclosed: ______________________
__________________________________________________________________________

Specific purpose of the disclosure: ___________________________________________
__________________________________________________________________________

This authorization will expire __________________ (indicate date, or an event relating to
you personally or to the purpose of the authorization).

II. Important Information About Your Rights
I have read and understood the following statements about my rights:
  • I may revoke this authorization at any time prior to its expiration date by notifying the Pharmacy in writing, but the revocation will not have any affect on any actions the Pharmacy took before it receive the revocation.
  • I may see and copy the information described on this form if I ask for it.
  • I am not required to sign this form to receive my health care benefits (enrollment, treatment, or payment).
  • The information that is used or disclosed pursuant to this authorization may be re-disclosed by the receiving entity.

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    III. Signature of Individual or Individual's Representative
    ______________________________________________________ _____________________
    Signature of Individual or Individual's Representative              Date
    (Form MUST be completed before signing.)

    Printed name of the Individual's personal representative: ____________________________________________
    Relationship to the individual, including authority for status as representative: _______________________________