HIPAA RELEASE AND AUTHORIZATION

Medical Records. I hereby authorize The Spine Diagnostic and Pain Treatment Center to use or disclose the following: 

    Specific Medical Records: Last 2 office visit notes, All imaging records and all Procedure Notes

My medical records shall be disclosed to: Dr. John L. Uhl and Baton Rouge Orthopaedic Clinic

Purpose of Release: Transfer of medical records to Dr. John Uhl for continuity of care at Baton Rouge Orthopaedic Clinic (BROC)

Expiration. This authorization expires on: Valid for 1 year from the date signed

I understand that signing this authorization is voluntary and that my treatment will not be conditioned upon whether I sign this authorization. I understand that I have the right to revoke this authorization at any time by writing to the Releasor, except where uses or disclosures have already been made based upon my original permission. I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by HIPAA. I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.