Please send my medical record(s) to Sussex Pain Relief Center, LLC as I am consulting a pain specialist.
Address: 18229 Dupont Blvd, Georgetown, DE 19947
Fax: (302) 253-8028
Please release office notes from my last three visits, imaging report(s) from the last three years, any lab reports from the last year, as well as a recent H&P.
Please send a Letter of Discharge if available.
CONSENT
I authorize the release of all information indicated, and I am aware that the records released may contain information relating to psychiatric or psychological testing, physical abuse, or drug and alcohol abuse. If treatment is for substance abuse, I understand that my records are protected under the federal regulations governing confidentiality of Alcohol & Drug Abuse Patient Records, 42 C.F.R. Part 2, and cannot be disclosed without my written consent, unless otherwise provided for in the regulations. I understand that my records are also currently protected under the Federal privacy regulations within the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. Parts 160 & 164. I understand that my health information specified above will be disclosed pursuant to this authorization, and that the recipient of the information may redisclose the information and it may no longer be protected by the HIPAA privacy law. I authorize the release of HIV/HTLV/AIDS test results. The Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, noted above, however, will continue to protect the confidentiality of information that identifies me as a patient in an alcohol or other drug program from redisclosure. I understand that the covered entity seeking this authorization is permitted under the HIPAA regulations, in treatment, payment, enrollment or eligibility for benefits, and that by refusing to sign this authorization, I may be responsible for payment of services and/or may not be able to receive services. Please be advised we may update the address and fax number of the physician or provider facility as necessary.
NOTE: This consent is valid for 90 days. It may be revoked by the signer at any time.