Authorization for the Release of Confidential Information

Authorization for the Release of Confidential Information

Name of Patient Please Print

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState

Zip

Phone

Maiden Name or other name used for records

I hereby authorize (Please Print)

the following information from my records:

Type a question

Complete Health Record (s)Health Records from Dr. (s)Other

Write Dr's Names

Covering the period from

to

I understand that may revoke this authorization in writing at any time except to the extent that action has been taken in reliance on it and that in any event this authorization shall expire 180 days from the date of my signature unless specified in writing here

I understand and agree to pay a reasonable copying fee to cover the cost of transfer for litigation. I hereby release you and your personnel from all legal responsibility of liability that may arise from the act I have authorized above. Center for Spine, Sports and Physical Medicine is not responsible for completeness, legibility, or omittance caused by the copying of any medical records from another institution. I understand that may revoke this authorization in writing at any time, except to the extent that action has been taken in reliance on it and that in any event this authorization shall expire (180) days from the date of my signature, unless specified in writing here:

I understand that if the recipient authorized to receive the information is not a covered entity, e.g. insurance company or non-health care provider, the released information may no longer be protected by federal and state privacy regulations.

Signature of patient or patients representative

Date

Printed name of patients representative

Prohibition on redisclosure: This information which has been disclosed to you from confidential records is protected by federal law. Federal regulations (42 CFR part 2) prohibit you from making any further disclosure of this information except with the specific written consent of the person to whom it pertains. A general authorization for the release of medical or other information if held by another party is not sufficient for this purpose. Federal regulations state that any person who violated any provisionof this law shall be fined not more than $500 in the case of a first offense, and not more than $5000 in the case of each subsequent offense.