Authorization For Release Of Medical Records And Personal Health Information printable pdf download

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS AND PERSONAL HEALTH

INFORMATION

Instructions: Please complete, initial where appropriate and sign this form, blanks or items not checked are

assumed to be non-applicable or specifically not authorized for release. By signing this form, you are

authorizing the release of medical records and personal healthcare information from/to another facility.

I HEREBY AUTHORIZE RELEASE FROM: [ ] RIVERSIDE SPINE D/B/A ALLIANCE PAIN PHYSICIANS, OR

[ ] ___________________________________________________________________________

( NAME OF OTHER RELEASING FACILITY)

TO DISCLOSE THE INFORMATION SPECIFIED BELOW FROM THE HEALTH RECORD OF:

NAME (Last): ____________________________ (First): __________________________ (MI) ____

DOB: ____________

Social Security # ________________________ Phone: _______________

THIS INFORMATION IS TO BE DISCLOSED TO: (Include Address)

[ ] RIVERSIDE SPINE 7207 GOLDEN WINGS RD, JACKSONVILLE. FL 32244

[ ] ALLIANCE PAIN PHYSICIANS, 3622 MADACA LANE. TAMPA, FL 33618

FOR THE PURPOSE OF: [ ] Continued Treatment

[ ] Billing

[ ] Personal

[ ] Other: _____________

THE FOLLOWING INFORMATION IS TO BE DISCLOSED:

[ ] Entire Medical Record

[ ] Rehabilitation Documentation

[ ] Operative report

[ ] Emergency Report

[ ] History & Physical

[ ] X-ray (Imaging) Reports

[ ] Laboratory Reports

[ ] Billing Records

[ ] Consultation Reports

[ ] Discharge Summary

[ ] Radiology Reports

[ ] Other:

____ (Initial) I UNDERSTAND THAT THIS MAY INCLUDE information relating to HIV/AIDS, mental

health, treatment and screening for alcohol or drug abuse, and/or sexually transmitted diseases.

POSSIBILITY OF REDISCLOSURE: I understand that any information released may be subjected to re-

disclosure and no longer protected by state and federal regulation.

EXPIRATION AND REVOCATION: I understand that this authorization is valid for 6 months from the date I

sign it, or the duration of __________________ (event). I have the right to revoke this authorization in writing

at any time. The revocation will take place on the day it is received, except to the extent it has already been

acted upon or if the authorization was obtained as a condition of obtaining insurance coverage.

CONDITION OF TREATMENT: I understand the Riverside Pain Physicians d/b/a Alliance Pain Physicians

or agency cannot condition treatment upon signing this authorization.

_________________________________________

_____________________

Signature of Patient/Guardian/Legal Representative

Date Signed

_________________________________________

_____________________

Relationship to Patient

Witness/Date

Authorization For Release Of Medical Records And Personal Health Information

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