Welch Pasteur Allergy Medical Group, Inc

Anita Carmen Choy, MD. |. Hailen Mak, MD
211 Quarry Road, Suite 106 MC 5996,
Palo Alto, CA 94304
Ph: 650.322.3847  |  Fax: 650.322.3249

Authorisation for Release of Protected Health Information 

I authorise release of my Protected health Information as follows:

I understand all of the following:

» Only the records checked above will be release to the above stated Person/Facility

» A copy of this form will be released to the above stated Person/Facility

» Although prohibited, it is possible that my PHI may be re-disclosed by the facility receiving my records, therefore, Welch Pasteur Allergy Medical Group, Inc. has noresponsibility or liability as a result of the re-disclosure, and such information would no longer be protected by the HIPAA Privacy rule.

»I am entitled to a copy of this completed authorization form.

»This authorization is valid for one year from the date of signature unless I document a time frame of less than one year.

»I have a right to revoke this authorization at any time by sending a written request to: Welch Pasteur Allergy Medical Group, Inc, 211 Quarry Road Suite

106, Mail Code 5996, Palo Alto, CA 94304, Attn: HIPAA Privacy Officer.

»I understand that my decision to revoke this authorization does not apply to any release that may have taken place prior to the date of my revocation.

»A reasonable fee for copying, search and handling, as permitted by the state law, may be charged for copies of health care records.