AUTHORIZATION TO DISCLOSE HEALTH INFORMATION
Form A (disclosure at request of patient)

Explanation – Read before signing the authorization

     This authorization gives permission for Asthma Allergy and Pulmonary Associates to disclose health information about you.  You may revoke this authorization at any time except to the extent that we have relied on the authorization. To revoke this authorization, you must submit your revocation in writing to our privacy officer at the address listed below.

     Health information disclosed pursuant to this authorization may be re-disclosed by the recipient if the recipient is not subject to the privacy rule promulgated by the Department of Health and Human Services under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the re-disclosure is not otherwise prohibited by law.  A charge may be made for copying records.  Please discuss speak with the office staff if you have ant questions.

Current contact information for our Privacy Officer:

Asthma Allergy & Pulmonary Associates

Attn:  Charlotte A. Dennis

1015 Chestnut Street, Suite 1300

Philadelphia, PA  19107

(215) 923-7685 Fax:(215) 923-8230

Authorization

Print or type all information except the signature.

I have read and understand the above Explanation. I request and authorize Asthma Allergy & Pulmonary Associates to disclose health information pertaining to __________________________________________________ (patient name) in accordance with the following:

1. Covered health information - Provide specific description (for example,
medical records for services rendered by Asthma Allergy & Pulmonary Associates from
March 1998 to December 2001 or July 1998 lab reports):

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

2. Specific persons or class of persons to whom the covered information can
be disclosed:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

* Include mailing address if a copy is to be mailed.

3. Expiration of authorization - Provide date or event (for example, July 31, 2002
or when this authorization is revoked):

_____________________________________________________________________________

________________________________________             _____________________
Signature of patient or personal representative                                      Date
(or personal representative for the patient)

______________________________________
Name of personal representative

___________________________________________________________
Relationship to patient (or other authority to serve as personal representative)