Release of Information

Associated Surgeons & Physicians
Limited Patient Authorization for Disclosure of Protected Health Information
Please print all information. Form must be signed and dated.
Patient Name
Social Security #: last 4 digits
Date of Birth

MonthDayYear
Date
Street
City/State
Zip
Entity Providing Information:
Practice
Provider
Address
City/State/ Zip
Phone
Fax
Entity Receiving Information:
Name
Address
City, State, Zip
Phone
Fax
Description of information to be disclosed - I authorize the practice to disclose the following protected health information about me to the entity, person, or persons identified above: (please provide a written description of the information to be disclosed):
Entire patient record, including but not limited to: office notes; lab results; x-rays; hospital, nursing home, home health, hospice, and other physician records; record of HIV and communicable disease testing; record of mental health or substance abuse treatment; and financial history report.Office notes, labs and x-rays only.Only send the following:
Only send the following
Purpose of disclosure (please check the purpose of the disclosure or check patient request):
Type a question

Patient transferring to our care.Patient RequestProvider RequestOther
Expirations or termination of authorization: This authorization will expire one year from the date of your signature below, unless you specify an earlier termination. You must submit a new authorization after the expiration date to continue the authorization. You have the right to terminate this authorization at any time. You must notify our privacy manager, in writing, if you decide to terminate the authorization prior to the normal expiration date.
(Please list an earlier expiration if less than one year)
Right to revoke or terminate: As stated in our Notice of Privacy Practices, you have the right to revoke or terminate this authorization by submitting a written request to our Privacy Manager.

Non-Conditioning statement: The practice places no condition to sign this authorization on the delivery of healthcare or treatment.

Redisclosure: We have no control over the person(s) you have listed to receive your protected health information. Therefore, your protected health information disclosed under this authorization will no longer be protected by the requirements of the Privacy Rule and will no longer be the responsibility of the practice.
Signature

Clear
Relationship to Patient
Date

MonthDayYear
Date
Patient signature Copies of signed authorizations are available upon request.
Should be Empty:

Limited Patient Authorization for Disclosure of Protected Health Information

Entity Providing Information:

Entity Receiving Information: