Records' Release Form for Second Opinion

AUTHORIZATION TO RELEASE MEDICAL INFORMATION to MIDLANDS ORTHOPAEDICS & NEUROSURGERY, P. A.
Patient's Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date *

MonthDayYear
Date
Social Security Number
Phone Number*
Please enter a valid phone number.
I authorize the release of the following records for the specified dates of service from the Provider or Facility indicated below to Midlands Orthopaedics & Neurosurgery:
Release records from date of service Date* to date of service Date* .
Records to be released:*

Discharge SummariesECG/EEG/Cardiac CathEmergency ReportsHistory & PhysicalImagingLaboratory ReportsOperative NotesPathology ReportsProgress NotesRadiology ReportsOther
Select each condition below for which you authorize the release of information:*

Acquired Immunodeficiency Syndrome (AIDS)Human Immunodeficiency Virus (HIV) InfectionPsychiatric Care and/or psychological assessmentTreatment for alcohol and/or drug abuseNone of the aboveNot applicable
Name of Practice /Agency / Facility/ Person Records are Requested From:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax Number of Practice/Agency/Facility Records are Requested From:
Please enter a valid phone number.
Select the purpose of this release of records:*

Referral to a specialistDisability DeterminationInsurancePersonalWorkers' CompensationContinuation of CareChange of ProviderLegal InvestigationOther
RELEASE RECORDS TO: MIDLANDS ORTHOPAEDICS & NEUROSURGERY, P.A.

Street Address: 1910 Blanding Street City, State, Zip Code: Columbia, SC 29201

Phone: 803.256.4107 Fax: 803.933.6352

Email: newopinion@midorthoneuro.com
Who should receive the records at Midlands Orthopaedics & Neurosurgery?*

2nd Opinion / Take Over Care TeamOther
Please provide an active telephone number in the event we need to contact you*
I hereby authorize disclosure of the health information for the above named patient. This authorization is valid for 12 months from the date of signature. I understand that I may cancel this request with written notification but that it will not affect any information released prior to notification of cancellation. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal regulations. I understand that the medical provider to whom this is authorized to be furnished may not condition its treatment of me on whether or not I sign the authorization.
Signature

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