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.