Release of Medical Records to Panda

Release of Medical Records
Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Phone Number:*

Area CodePhone Number
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I request that: Physician* Practice Name* Practice Address*
Phone Number* Fax Number
Complete health recordsPhysical examImmunization recordLab results/X-Ray reportsConsultation reportsOther (please specify):
I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event, or condition:*
If I fail to specify an expiration date, event or condition, this authorization will expire in sixty days. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact:

Jennifer Taylor, the Privacy Officer at PANDA Neurology & Southeast Center for Headaches
Signature of patient or legal representative:*

Clear
Date:*

MonthDayYear
Date
Signature of witness:*

Clear
Date:*

MonthDayYear
Date
Should be Empty: