Surgery South - HIPAA Authorization

Authorization to Release Protected Health Information

Surgery South, P.C.
Unless you the patient (or legal representative) authorize the release of information regarding your evaluation and treatment at Surgery South, P.C. to anyone other than yourself. INFORMATION CAN NOT BE SHARED OR QUESTIONS ANSWERED REGARDING YOUR CARE AT THIS FACILITIY.
I, (insert name below), authorize Surgery South, P.C. to release my protected health information to the following:

First NameLast Name

IN CASE OF EMERGENCY*

Authorization to Release Protected Health Information