First-time Patient Disclosure Authorization (Form 3 of 3)

We take privacy seriously and will not disclose any patient’s personal health information without the appropriate consent. With that said, we also embrace a collaborative approach to health care and are often asked by patients to share their information with those involved in their care, like physicians and nurse practitioners.

This form authorizes Vireo Health of New York to disclose a patient’s personal health information.  I understand that by signing this form, I am authorizing that personal health information may be sent to the person(s) and/or organizations(s) listed. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may not be protected by any privacy procedures or laws. I may stop this consent at any time by writing to Vireo Health of New York. If Vireo Health of New York has already released health information based on my consent, my request to stop cannot be retroactively applied. I understand that this form is optional and Vireo Health of New York will not condition dispensing medication or providing treatment to me based on whether or not I sign this consent form.