madisonpodiatrists.com - Authorization to Disclose Protected Health Information

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION
Patient’s Name:
DOB:

MonthDayYear
Date
Previous Name:
SS No.
I request and authorize Type a label to release healthcare information of the patient named above to:
Name:
Address:
Phone/Fax No.s:
INFORMATION REQUESTED

Medical Record - Entire RecordProgress NotesOperative ReportsLaboratory ResultsNurses NotesX-Ray ReportsRadiology FilmOther
Identify date of service or date ranges requested including month and year: Date To Date
THIS RECORD IS REQUESTED FOR THE FOLLOWING REASON:

Continued Medical CareLegal PurposesInsurance PurposesPersonal InterestOther
The authorization must be signed and dated and may be revoked by notifying Associated Podiatrists LLP in writing at any time except to the extent action has been taken prior to revocation. This consent will expire 60 days after the date below or sooner by my choice, in which case this consent will expire on this date or event Type a label . Such expiration date or event has not occurred.
REQUEST FOR RECORD COPY RELEASE WILL BE HANDLED WITHIN 3 BUSINESS DAYS OF RECEIVING REQUEST
REQUEST FOR RECORD COPY RELEASE WILL BE HANDLED WITHIN 3 BUSINESS DAYS OF RECEIVING REQUEST
- Requests for copies for personal use will incur a charge of 25¢ per page. All other forwarded at no charge.
  * Free copies exclude copies of x-ray films. A separate fee of $10 each film will be assessed if these items are requested.
I understand that the medical record released pursuant to this authorization could contain information concerning drug related conditions, alcoholism, psychological conditions, psychiatric conditions, and/or blood borne infectious disease, which are subject to federal and/or state restrictions on disclosure. I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be redisclosed and no longer protected by these regulations. I hereby affirm that I have read and fully understand the above statements and consent to the disclosure of the medical record for the purpose and extent stated above.
Signature (Patient, Parent or Legally Authorized Representative)

Clear
Date:

MonthDayYear
Date
Relationship to the Patient:
Phone Number:
Please enter a valid phone number.
PROHIBITION ON REDISCLOSURE: This information has been disclosed to you from records whose confidentially is protected by federal and/or state law. Federal and state regulations prohibits you (the recipient) from making any further disclosure without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.

6510 Grand Teton Plaza • Suite 406 • Madison, WI 53719 • ph: 608.829.2535 • fx: 608.829.1319
4237 Lien Road • Suite A • Madison WI 53704 • ph: 608.244.1772 • fx: 608.244.5518

footdr@madisonpodiatrists.com • www.madisonpodiatrists.com
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AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

REQUEST FOR RECORD COPY RELEASE WILL BE HANDLED WITHIN 3 BUSINESS DAYS OF RECEIVING REQUEST