hiltonheadorthopedics.com - Patient Authorization

PATIENT AUTHORIZATION FOR RELEASE OF MEDICAL RECORD
I hereby authorize Joseph P. Tobin, M.D. and Tobin Bone and Joint Surgery, Inc. to release to:
Type a label any and all of my records pertaining to medical care, history, condition, treatment, diagnosis, prognosis or expenses.
I further authorize and direct Joseph P. Tobin, M.D. and Tobin Bone and Joint Surgery to provide to the above person or entity any written or oral reports pertaining to these same matters.
A photocopy of this form shall have the same force and effect as the original.
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PATIENT AUTHORIZATION FOR RELEASE OF MEDICAL RECORD