Sansum Clinic
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Authorizations

You may be asked to sign an authorization when Sansum Clinic is requesting permission to use your protected health information for purposes other than treatment, payment or health care operations, or to disclose this information to a third party for purposes not outlined above in Section II. Examples include: disclosing information to an employer for employment decisions, or disclosing information for eligibility for life insurance. Additionally, an authorization will be required to use or disclose psychotherapy notes for treatment by persons other than the originator of the notes.

Click in the links below to download and print our authorization for disclosure forms in English or Spanish:

Authorization for Use/Disclosure of Protected Health Information

Autorización Para Su Uso/Divulgación De Información Confidencial De La Salud

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