Release of Information Consent for Family Members/Caretakers/Spouse

 

If Yes: I authorize ASPIRE MEDICAL GROUP to release my medical and/or billing information to the following individial(s). Please indicate Name(s) and Relationship for each person. Example: 1. John Smith (Husband)
Please read and sign the document

Patient Information: I understand the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed. I understand that information disclosed to any above recipient is no longer protected by federal or state law and may be subject to redisclosure by the recipient. You have the right to revoke this consent in writing. *

Yes

No
Patient or Authorized Representative Signature *

 1. I certify that I have read this authorization form in its entirety and fully understand its contents. I have had the opportunity to ask questions and seek clarification on any unclear points, and all my questions have been answered to my satisfaction.

 2. I understand that Aspire Medical Group cannot control how the recipient uses or shares the information, and that laws protecting confidentiality at Aspire Medical Group may not apply once the information is released to the recipient.

3. I understand that this authorization is voluntary. My treatment or eligibility for benefits will not be affected if I do not sign this form.

4. I understand that I may revoke this authorization at any time by submitting a written request to the department or office where I originally submitted it. However, if Aspire Medical Group has already processed the request (e.g., once information is released, it cannot be retrieved), or if I signed this authorization as a condition of obtaining insurance, cancellation may not apply. Further release of information will cease, except as required by law, upon Aspire Medical Group's receipt of written revocation.

5. This authorization will automatically expire one year from the date signed, unless otherwise specified.

6. If Aspire Medical Group maintains any of my records from outside providers, these will not be released unless specifically requested. Please include the entity name, provider, and specific dates if known in the "Other" section (Section C).

7. By providing my electronic signature below, I agree to the terms and conditions outlined in this agreement. I agree to the use of electronic records and signatures. I acknowledge that I have read the related consumer disclosure.

8. The parties acknowledge and agree that this consent agreement form may be executed by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature. Without limitation, “electronic signature” shall include faxed versions of an original signature or electronically scanned and transmitted versions (e.g., via PDF) of an original signature.