Authorization for Release of Information

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

Patient Name *

First Name Middle Name Last Name

Email *

example@example.com

Old Bull Sports Medicine and Rehabilitation will only disclose the protected health information you want disclosed. Check only one box to tell Old Bull Sports Medicine and Rehabilitation 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/Examination Attendance Correspondence re: your Physical Therapy Services Past Medical History Treatments Other

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 Name Last Name

Attorney

First Name Last Name

Parent

First Name Last Name

Employer

First Name Last Name

Friend

First Name Last Name

School

Other

Section #5 - Check only one box indicating how long Old Bull Sports Medicine and Rehabilitation can use this authorization:

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

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 above I understand that I can refuse to give authorization without fear of retaliation or treatment limitations I understand that if I give authorization I may revoke it at any time by notifying this Old Bull Sports Medicine and Rehabilitation in writing I 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 possession I understand that if Old Bull Sports Medicine and Rehabilitation requests my authorization it is required to tell me the purpose and to whom my PHI (protected health information) is being released to I understand that I will receive a copy of this authorization after I sign it and before I sign, if I request it Old Bull Sports Medicine and Rehabilitation 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