By signing this authorization, I authorize Athens Spine Center (the “Practice”) to use and/or disclose certain protected health information (PHI) to or for the party or parties listed below. 

What PHI may be used or disclosed: 

This Authorization permits the Practice to use or disclose the following PHI:

 appointment information, medical records, and billing information  

Describe the specific purpose(s) for which you authorize the Practice use or disclose this PHI:

 for the processing of workers compensation claims, authorizations and case management  

To whom may the PHI be disclosed:[This may be inapplicable if Athens Spine Center is going to use the PHI for its own purposes and not disclose it to a third party.]

Entity Name: Workers’ Compensation Case Manager & Adjuster  
 

This authorization will expire: one year from the date this form was completed  

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, by sending a written request stating that I wish to revoke this Authorization to the attention of the Practice Administrator.

I understand that the Practice may not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this Authorization.