Patient Request for Treatment Release

Patient Name*

First NameMiddle NameLast NameSuffix

Date of Birth*

Email

example@example.com

I would like to request release from pain management treatment from Athens Spine Center physicians. By signing this form I understand that I will no longer be under the care of Athens Spine Center physicians effective the date signed below. I also understand that I will have to have a new referral if I wish to return under the care of Athens Spine Center physicians.

Reason for treatment release:*

By signing this form, 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.: 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*

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*