middletownpodiatry.com - Authorization for Release

Authorization for Release of Protected Health Information
I understand that, by completing the form, below, if my Protected Health Information contains information related to the history, diagnosis and/or treatment of any of the listed situations, that my signing this document authorizes Middletown Foot & Ankle to release that information. I acknowledge and am aware that New Jersey has a statutory privilege accorded to confidential communications between a patient and a licensed physician or psychologist and that my signing this form waives this privilege.
Patient's Name:
Parent/Guardian (if under 18):
Patient's Date of Birth:

MonthDayYear
Date
I authorize the Middletown Foot & Ankle to disclose my protected health information including the following records
Click all that apply

Chart NotesLab ReportsImaging Reports
Indicate the name of the office where records are to be sent
Address
Phone Number and Fax Number
This consent may be revoked at any time by writing to Middletown Foot & Ankle by mail or email at info@axispodiatry.com unless our office has already taken action in reliance on this authorization. If not previously revoked, this consent will terminate after 6 months.

Middletown Foot & Ankle will not make decisions concerning treatment, payment, enrollment or eligibility for benefits based on signing, refusing to sign or revoking this authorization.

I acknowledge and understand that uses and disclosures of my protected health information authorized by this document may be subject to redisclosure by the recipient and may not be protected by privacy and confidentiality laws.
Patient's Signature

Clear
Date signed:

MonthDayYear
Date
Patient/Guardian Signature

Clear
Date signed:

MonthDayYear
Date
Should be Empty:

Authorization for Release of Protected Health Information