213 Greenhill Ave. Wilmington, DE 19805
(302) 429-5870
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Family Medicine at Greenhill PHI Use and Disclosure Authorization

This form authorizes the use or disclosure of protected health information in the manner described below and is voluntary. Family Medicine at Greenhill will still provide medical treatment if you do not sign this authorization, except under limited circumstances that are described in our Notice of Privacy Practices. Please be aware that once your information leaves Family Medicine at Greenhill, Family Medicine at Greenhill will no longer be able to protect that information, and the recipients of your information may not be legally required to protect your information.

Date of Birth
Purpose of Disclosure:
Please include full name, relationship & phone number.
Please include full name, relationship & phone number.
Release of the following information requires specific authorization. Check all that apply:

I understand that I have the right to terminate or revoke this authorization at any time. To do so, my request must be provided to your office in writing. Written requests can be sent to Cheryl Mongillo, Privacy Officer, Family Medicine at Greenhill, 213 Greenhill Avenue, Suite B, Wilmington DE 19805. I understand that revocation is not effective if my authorization was obtained as a condition of obtaining insurance coverage.

I understand that information that is disclosed under this authorization may be disclosed under this authorization may be disclosed by the recipient, as such the privacy of this information may not be protected under the Federal Privacy Rule depending on whom the information is disclosed to. I understand that my authorization is not required as a condition to receive treatment, payment, or enrollment or eligibility for benefits.

Electronically Signed
I, the undersigned, acknowledge and agree that by typing my name, clicking “I Accept,” or by other electronic means, I am signing this document electronically.