Authorization to Release Information

My name is       telephone number and I give my permission to release protected health information (including medication lists and diagnoses) to Philip Leung RPH, BCGP for the purpose of Medication Therapy Management.  The following pharmacies and doctors are allowed to release information:




This authorization is effective starting  and ending 60 days later.

HIPAA Notice of Privacy Practices has also been received by me.

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Signature Certificate
Document name: Authorization to Release Information
lock iconUnique Document ID: ebd462cb0c0c2c3f1ed0092b2caad3a8677dece7
Timestamp Audit
January 2, 2018 1:05 pm EDTAuthorization to Release Information Uploaded by PHILIP LEUNG - [email protected] IP