Authorization for Release of Information

Authorization for Release of Information
Locations:

Old Bull Athletics, Coral Gables
169 Majorca Avenue
Coral Gables, FL 33134

Old Bull Athletics 2, Pinecrest
8185 SW 117th Street
Pinecrest, FL 33156
Authorization is not required for the Use or Disclosure of Information
Related to Treatment, Payment, Healthcare Operations or if Required by Law or Rules
HIPAA 143a-Authorization for Release of PHI 10-28-08
You May Refuse to Sign this Authorization
Patient Name*

First NameMiddle NameLast Name
Email*
example@example.com
Old Bull Athletics, Inc., Old Bull Sports Medicine and Rehabilitation LLC, and Old Bull Athletics 2 LLC will only disclose the protected health information you want disclosed. Check only one box for the specific information you want disclosed/released:*

Do NOT release any information other than for treatment or payment (skip #’s 3, 4, and 5)Limited information (complete ALL Sections)ALL records regarding my care at Old Bull Athletics to any requesting party (skip 3 and 4)
Section #3 - Complete only if you selected “limited information”. Please check all that apply:

Evaluation/ExaminationAttendanceCorrespondence re: your Physical Therapy ServicesPast Medical HistoryTreatmentsOther
Section #4- Complete only if you selected “limited information”. I only authorize the release of information to the individuals/entities identified below by name:
Signature*

Clear
Spouse

First NameLast Name
Attorney

First NameLast Name
Parent

First NameLast Name
Employer

First NameLast Name
Friend

First NameLast Name
School
Other
Section #5 - Check only one box indicating how long Old Bull Athletics, Inc., Old Bull Sports Medicine and Rehabilitation LLC, and Old Bull Athletics 2 LLC can use this authorization:

Disclose my information indefinitely (as long as Old Bull Sports Medicine and Rehabilitation (and Old Bull Athletics, Old Bull Athletics 2) has custody of my files)Disclose my PHI for the following period beginning and ending
Date beginning to disclose PHI

MonthDayYear
Date
Date beginning to end disclosure of PHI

MonthDayYear
Date
Please checkall items below indicating that you have read and understand the rights or information below:*

I understand that this authorization does not expire unless I have indicated an expiration date aboveI understand that I can refuse to give authorization without fear of retaliation or treatment limitationsI understand that if I give authorization I may revoke it at any time by notifying this Old Bull Athletics, Inc., Old Bull Sports Medicine and Rehabilitation LLC, and Old Bull Athletics 2 LLC in writingI understand that the information used/disclosed as a result of my authorization may be subject to re-disclosure by the recipient and may not be protected by Federal privacy regulations once in the recipient’s possessionI understand that if Old Bull Athletics, Inc., Old Bull Sports Medicine and Rehabilitation LLC, and Old Bull Athletics 2 LLC requests my authorization it is required to tell me the purpose and to whom my PHI (protected health information) is being released toI understand that I will receive a copy of this authorization after I sign it and before I sign, if I request itI understand that I will receive a copy of this authorization after I sign it and before I sign, if I request it Old Bull Athletics, Inc., Old Bull Sports Medicine and Rehabilitation LLC, and Old Bull Athletics 2 LLC will not be compensated for using or disclosing my PHI unless related to treatment or payment procedures unless specific permission is obtained by the patient after full disclosure of purpose and intent. You May Refuse to Sign this Authorization.
Signature

Clear
Old Bull Athletics, Inc., Old Bull Sports Medicine and Rehabilitation LLC, and Old Bull Athletics 2 LLC.
Should be Empty:

Authorization for Release of Information

You May Refuse to Sign this Authorization