Authorization for Disclosure of Protected Health Information

I, the above-named Releasor, hereby authorize the above-named Releasee to release the following health information to:

Louisiana Pain Care
210 Layton Avenue
Monroe, LA 71201
(318) 323-6405
(318) 807-0239 Medical Records Fax #

The protected health information is being disclosed for the following purposes:

Pain Management & Continued Treatment

This authorization shall remain effective from the time of execution of this document until: 

I understand that I have the right to revoke this authorization, at any time by sending written notice to this healthcare provider. I understand that a revocation is not effective: 1) To the extent that this health care provider has relied on the use or disclosure of the protected health information; or 2) If the authorization is obtained as a condition of obtaining insurance coverage, if some other law or the policy itself provides the insurer with the right to contest a claim under the policy.

I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state laws.

I understand that this health care provider may know my condition of treatment, payment, enrollments in a healthcare plan, or eligibility for benefits (if applicable) on whether I provide the authorization for the requested use or disclosure.

I understand that I have the right to: 1) Inspect or copy the protected health information to be used or disclosed as permitted under the federal law, or state law to the extent the state law provides greater access rights: and 2) Refuse to sign this authorization