Medical Records Release

Patient Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Email
example@example.com
Medical Records Release Form

Authorization for the Disclosure of Protected Health Information
By signing this authorization, I authorize Athens Spine Center, PC to use and/or disclose the following Protected Health Information (PHI) for the following purpose(s) to the party/parties listed below:
What PHI may be disclosed (type ALL for the entire chart)*
Specifically describe the information to be released, i.e.: date(s) of service, level of detail to be released, origin of information, etc
Describe the purpose(s) for which you are authorizing this disclosure*
i.e.: Continuation of Care, Transfer of Care to another provider, etc.
To whom may the PHI be disclosed:
Practice Name / Physician Name*
Contact Person
Address*
Phone Number*

Area CodePhone Number
Fax Number*

Area CodeFax Number
Practice Name / Physician Name
Contact Person
Address
Phone Number

Area CodePhone Number
Fax Number

Area CodeFax Number
This authorization will expire:*
Specific expiration date must be provided. If no date is listed, this authorization will expire 60-days from date of signature
I understand that when my PHI is disclosed pursuant to this Authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing, except (i) to the extent that the Practice has acted in reliance upon this Authorization; or (ii) to the extent that the Authorization was obtained as a condition of obtaining insurance coverage, there is other law that grants the insurer the right to contest a claim under the policy. I understand that my revocation must be submitted in writing to the Practice’s Administrator at 830 King Avenue, Athens, GA 30606.
Signature*

Clear
Name of Patient or Personal Representative [If signed by a Personal Representative, please state such person's authority to act for the individual]:

First NameLast NameRelationship to Patient
Date Signed*

MonthDayYear
Should be Empty:

Medical Records Release Form