Release of Information to BGH Orthopedics

Authorization for Release of Information

Bonner General Orthopedics | 606 N Third Ave. Suite 201 Sandpoint, ID 83864 | Ph (208) 265-1011 | Fax (208) 265-6271
I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand this authorization is voluntary. I understand if the organization authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations.
Patient Name
Date of Birth

MonthDayYear
Date
MR #
I hereby authorize Bonner General Orthopedics to release my health information to:
I hereby authorize Bonner General Orthopedics to obtain my health information from:
Specific description of information (including date[s]):
1. I understand that this authorization will expire on Date
Initials Initial Here.
2. I understand that I may revoke this authorization at any time by notifying Bonner General Orthopedics in writing. It will not have any affect on any actions that were taken prior to the revocation. Initials Initial Here
Signature of patient or patient's representative (Form MUST be completed before signing)

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Date

MonthDayYear
Date
Printed name of patient’s representative
Relationship to patient
*YOU MAY REFUSE TO SIGN THIS AUTHORIZATION
PROHIBITION OF REDISCLOSURE: This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulations (42 CRF part 2) prohibit you from making further disclosure of this information except with the specific written consent of the person to whom it pertains. A general authorization for release of medical or other information if held by another party is NOT sufficient for this purpose.
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Authorization for Release of Information

*YOU MAY REFUSE TO SIGN THIS AUTHORIZATION