AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

Steven D. Graham, PhD, DMin 

I understand that:

  • I have a right to revoke this authorization in writing except to the extent that Dr. Graham has taken action or has relied on the authorization. I may revoke this authorization in writing by delivering a copy of my revocation to Dr. Graham.
  • My treatment does not depend on my providing authorization for this use or disclosure of my protected health information. 


Signature: _______________________________________  Date:____________ 

Signature of personal representative of patient: _________________________________ 

Representative’s relationship to patient: _____________________________

Steven D. Graham, PhD, DMin