FACULTY INTERNAL MEDICINE

FACULTY INTERNAL MEDICINE
Authorization to Disclose Protected Health Information

The undersigned authorizes to release my health information as noted below
Patient Full Name *
Other Names
Date of Birth *

Month Day Year
Date
Last 4 digits of SS#
Patient Address
City
State
Zip
Phone #
Release Information From *

Faculty Internal Medicine 2250 Sutherland Ave Ste 121 Knoxville, TN 37919 Faculty Internal Medicine 11440 Parkside Dr. Ste 302 Knoxville, TN 37934
Information to be released to:
Name/Facility *
Attention
Address

Address

Street Address Line 2

City State

Zip
Phone
Fax #
Purpose of Request

Personal Treatment Insurance Transfer Other: Legal
Information to be Released:

Please release all records Last 2 years Office notes/Labs/Radiology including cardiac testing; most recent diagnostic procedures Colonoscopy & DEXA, etc: all Vaccinations. Specific:
Authorization to Release Protected Health Information
I acknowledge and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results, or AIDS information. Initial. (Please Initial)
1. I may refuse to sign this authorization and that it is strictly voluntary.
2. My treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization.
3. I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken prior to receiving the revocation. Unless otherwise revoked, this authorization will expire on the following date, event or condition: List Date
4. I understand that information used or disclosed pursuant to this authorization may be subject to re disclosure by the recipient and no longer be protected by Federal privacy regulations.
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Please confirm that you have filled out this form in its entirety-if form is incomplete, or if protected information is not released, we may be unable to fulfill this request.
Signature *

Signature of Patient Legal Guardian/Parent/Authorized Person Clear
Date *

Month Day Year
Date
Should be Empty:

FACULTY INTERNAL MEDICINE

Information to be released to:

Authorization to Release Protected Health Information

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