Authorization for Use and Disclosure of Patient Health Information

Authorization for Use and Disclosure of Patient Health Information
Patient's Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com
Patient Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please disclose the following protected health information to:

Name of facility, physician, or attorney this information will be given to — including address and phone number.
Records from:

Complete Medical RecordsMedical Records for the following dates only:
Date from:

MonthDayYear
Date
Date to:

MonthDayYear
Date
Records sent to:
Preferred Delivery Method:
Check one:*

Email or Electronic DeliveryStandard MailPick up at ORA Orthopedics office
If you are picking it up in person, indicate which ORA clinic below.
Bettendorf, Davenport, Moline, Silvis
I hereby authorize ORA Orthopedics to disclose:
Select all that apply:*

Clinic Office NotesPhysical Therapy NotesLaboratory ReportsOperative NotesRadiology ReportsRadiology (X-Ray & MRI) Images - Images will be electronically delivered.Other
Purpose of Disclosure:
Select all that apply:*

Transfer of records to new providerInsuranceWorkers CompMilitaryLegal/AttorneyDisability determinationPersonal
I understand that I have the right to revoke this authorization at any time by sending a written revocation to ORA Orthopedics, Privacy Officer. If I revoke this authorization, ORA Orthopedics will no longer use or disclose my medical information for reasons covered by this authorization, except to the extent it already has relied upon this authorization. I understand that when ORA Orthopedics discloses information pursuant to this authorization, the information may no longer be protected by federal or state privacy rules and may be subject to re-disclosure by the recipient of this information.

I understand that I need not sign this authorization to assure treatment. I understand that I may inspect and/or copy the information to be disclosed. I understand that authorizing this disclosure is voluntary. I understand that if I have questions about disclosure of my health information, I may contact the ORA Orthopedics’ Privacy Officer.
Specific Authorization for Release of Information Protected by State or Federal Law:

I understand the information below may be released and may include the following categories unless I specifically deny the release (initial any category not to be released):
Substance Abuse (Alcohol/Drug Abuse):

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Initial
Mental Health (Psychological Testing):

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Initial
HIV Related Info (AIDS-Related Testing):

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Initial
This authorization will expire one year from the patient signature date.

I understand and agree to the terms of this authorization:
Signature:*

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Date:*

MonthDayYear
Date
If signed by Patient Representative, state authority to act on behalf of patient:
Should be Empty: