IVPCARE Fertility Pharmacy – Infertility treatments and medications

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In order for IVPCARE to communicate with other individuals regarding your protected health information you will need to complete and submit the form below.

Please fill out the Release Form below

DOWNLOAD the form and send to:
Ivpcare, Inc
7164 Technology Drive. Suite 100.
Frisco, TX 75034
Fax: 800.874.9179

- Please review our Privacy Notice for more information.

AUTHORIZATION FOR USE OR RELEASE OF INFORMATION

* = required fields

Section A: Must be completed for all authorizations

I hereby authorize the use or disclosure of my individually identifiable health information (“Protected Health Information” or PHI) as described below in this form (this “Authorization”) by IVPCARE, a Texas corporation (“ivpcare”).

* Patient's Name :
* SSN :	- -
* Email :

Name of person(s) or organization(s) authorized to use or receive the Protected Health Information:
*

Specific description of Protected Health Information to be used or disclosed:
All pertinent PHI held by IVPCARE.

Please fill in a date or an event on which this Authorization will expire (do not fill in both):
Date: ___/___/____ Event: Upon written request from patient.

Please read the following and check each box upon completion:
*	I understand that my Protected Health Information is subject to redisclosure to the authorized recipient of the Protected Health Information pursuant to this Authorization.
*	I understand that I may revoke this Authorization at any time by notifying ivpcare in writing, but if I do, it will not have any effect on any actions ivpcare took before it received the revocation of this Authorization.
*	I understand that if the entity or organization that I authorize to receive my Protected Health Information under this Authorization is not a health plan, a health care clearinghouse or health care provider, the released Protected Health Information may no longer be protected by federal privacy regulations.

Section B: The patient or the patient’s representative must read and initial the following statements:

Please read the following and check each box upon completion:
*	I understand that I may refuse to sign this Authorization, and that my health care treatment, payment, enrollment or eligibility for benefits will not be conditioned upon signing this form.
*	I understand that I have the right to receive a copy of this Authorization after I sign it.
*	I understand that I may see and copy the Protected Health Information described on this Authorization if I request to do so.

Statement: *

	I agree to the above terms and conditions.
	I do not agree to the above terms and conditions.