HIPAA Release

Patient Name*

First NameLast Name

Birth Date*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Email

example@example.com

Many of our patients allow family members such as their spouse, parents or others to call and request medical or billing information. Under the requirements of HIPAA we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your medical or billing information released to family members you must sign this form. Signing this form will only give information to family members indicated below.

I authorize Legacy Spine and Neurological Specialists, Legacy Neurosurgery, Legacy Neurology, Pavilion MRI and Legacy Surgery Center to release my complete medical and/or billing information to: Please input Person's Name

Relationship to Patient

I authorize Legacy Spine and Neurological Specialists, Legacy Neurosurgery, Legacy Neurology, Pavilion MRI and Legacy Surgery Center to release my complete medical and/or billing information to: Please input Person's Name

Relationship to Patient

I authorize Legacy Spine and Neurological Specialists, Legacy Neurosurgery, Legacy Neurology, Pavilion MRI and Legacy Surgery Center to release my complete medical and/or billing information to: Please input Person's Name

Relationship to Patient

I authorize Legacy Spine and Neurological Specialists to make disclosures to the following organizations or doctors:

Patient Information:

This notice will expire one year from date signed unless “forever” or additional date is noted. If you do not specify an expiration date this authorization will expire in 1 year.

Expiration date:

By signing this form I understand I have 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 the information in my record may include information relating to sexually transmitted diseases, AIDS, or HIV. It may also include information about behavioral or mental health services or treatment for alcohol and drug abuse.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 above recipient. You have the right to revoke this consent in writting. *

Date Signed

Date