Premierheartnj.com - Authorization for Release of Information

Authorization for Release of Information
Patient Name:
Date of Birth:

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I authorize the use or disclosure of the {patientName} health information as described below.
Previous Treating Facility or Office Name:
Address:
Phone Number
Please enter a valid phone number.
Fax
Treatment Dates:
Treatment Dates:
The type of information to be used or disclosed is as follows:

Treatment/visit notesEKGReportsMedication listsLab resultsRadiology ReportsConsult notesOther
The type of information to be used or disclosed is as follows:
Treatment/visit notes
EKG
Reports
Medication lists
Lab results
Radiology Reports
Consult notes
Other
This information may be disclosed to and used by the following individual or organization:

Premier Heart, LLC

151 Fries Mills Road, Suite 105

Turnersville, NJ 08012

Office: 856-212-0130, Fax: 856-212-0135

I understand that information in my health record may include information relating to Human Immunodeficiency virus (HIV), AIDS (Acquired Immune Deficiency Syndrome), psychological or psychiatric conditions or treatment, sexually transmitted diseases or drug/alcohol, abuse/ dependence status, detoxification or rehabilitation services. I understand that I have the right to revoke this authorization at any time. I understand if I revoked this authorization I must do so in writing and present my revocation to Premier Heart. I understand that the revocation will not apply to information that has already been released in response to this authorization. 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 Type a label . If I fail to specify an expiration date, this authorization will expire in 1 year. I understand that authorizing the disclosure of health information is voluntary and I can refuse to sign the form if I do not wish this request processed. I do not need to sign this form to assure treatment. I understand I may inspect or obtain a copy of the information to be used or disclosed. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules.
Disclose Information To
First name and last name or Medical facility.
Fax Number
Please enter a valid phone number.
Signature of Patient or Legal Representative:

Clear
Date:

MonthDayYear
Date
If signed by legal representative, relationship to patient:
Should be Empty: