HIPAA Records Release Form | Caradigm Patient Advocates

Date

To:*

Attn:*

Name*

First Last

Date of Birth*

Account Number*

Email*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

I HEREBY GRANT AND AUTHORIZE Ken Kwapiszewski R.Ph. OF Caradigm Patient Advocacy, LLC ACCESS TO ANY MEDICAL RECORDS, REPORTS, CORRESPONDENCE, INSURANCE INFORMATION, AND BILLING INFORMATION AS REQUESTED

From

Through

I authorize Caradigm Patient Advocacy LLC to correspond through any medium with you regarding the above. Should you have any questions, please call Caradigm Patient Advocacy.

Please address mailed correspondence to:
Ken Kwapiszewski, R.Ph.
Caradigm Patient Advocacy, LLC
17525 N Fruitport Rd. Spring Lake MI 49456

Other authorized contact information:
Phone: 616-414-4694
Email: ken@caradigmadvocacy.com

Please accept a Photostat copy of this authorization with the same authority as the original.

Signature*

Please type your full name as signature.

Date of Signature*

Acknowledgement*

By my signature above, I acknowledge the release of any Protected Health Information (PHI) to Caradigm Patient Advocacy as designated on this release form. This protected health information is to be disclosed under this authorization at my request, as permitted by 164.508©(1)(iv) of the privacy regulations issued pursuant to the Health Insurance Portability and Accountability Act (“HIPAA Privacy Rule”). I acknowledge that I have received a copy of this authorization. This authorization will remain in effect until revoked. I understand that I have the right to revoke this authorization in writing, at any time, by sending a written request for the revocation to Caradigm Patient Advocacy.

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