Keystone Advanced Therapies is authorized to release protected health information about the above-named patient to the entities named below. The purpose is to inform the patient or others in keeping with the patient's instructions.

Entity to Receive Information

Description of Information to be released.

Check each person/entity that you approve to receive information.

Entity to Receive Information:
  • Voicemail (results of lab tests / x-rays)
  • Spouse (name & phone number)
  • Parent (name & phone number)
  • Other (name & phone number)
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PATIENT INFORMATION:

I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copy the PHI to be disclosed as described in this document. I understand that a revocation is not effective in cases where the information has already been disclosed but will be effective going forward. I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. This authorization shall be in effect until revoked by the patient.

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