AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Jack L. Koch Jr., M.D.

1507 16th Ave. South

Nashville, TN 37212

Phone: (615) 515-7775

Fax: (615) 523-1483
AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION
Patient Name*

First NameMiddle NameLast NameSuffix
Patient Date of Birth*

MonthDayYear
Date
Guardian's Name (if applicable)

First NameMiddle NameLast NameSuffix
I hereby request and authorize:
Name of person/organization to/from the information is to be released*
Address
City
State
Zip Code
Phone*
Fax*
To release healthcare information of the patient named above*

ToFromBoth
Jack L. Koch Jr., M.D.

1507 16th Avenue S.

Nashville, TN 37203

Phone: (615) 515-7775

Fax: (615) 523-1483
This request and authorization applies to:*

Healthcare information relating to the following treatment, condition, or dates:All healthcare informationOther:
Healthcare information relating to the following treatment, condition, or dates:
Other:
The purpose/intended use of the information to be disclosed*
I understand the following: See CFR $164.508(c2i-iii)

1.I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization.

2. The information released in response to this authorization may be re-disclosed to other parties.

3. My treatment or payment for my treatment cannot be conditioned on the signing of this authorization.

Any facsimile, copy or photocopy of the authorization shall authorize you to release the records requested herein. This authorization shall be in force and effect until two years from date of execution at which time this authorization expires.
Signature of Patient or Legally Authorized Representative *

Clear
(See 45CFR § 164.508(c)(1)(vi))
Date*

MonthDayYear
Date
Name/Relationship of Legally Authorized Representative to Patient
(See 45CFR $164.508(c)(1)(iv))
Date

MonthDayYear
Date
Witness Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Jack L. Koch Jr., M.D.

1507 16th Ave. South

Nashville, TN 37212

Phone: (615) 515-7775

Fax: (615) 523-1483

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION