Authorization For Release Of Medical Information Form printable pdf download

TOWN CENTER ORTHO ASSOC (TCOA)

1860 TOWN CENTER DRIVE #300

RESTON, VA 20190

Ph 703-435-6604

Fax 703-787-6575

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

________________________________________

_____________________________

(Print patients full name)

Birth date (Mo/Day/Yr)

________________________________________

_____________________________

(Street address)

Social security number (optional)

________________________________________

______________________________

)

(City, state, zip code

Phone (Home)

________________________________________

______________________________

(Parent/Guardian if Patient<18 yrs)

At the request of the individual, I ________________________________, do hereby authorize TCOA t

o release:

Patient Name

SERVICE DATES OF______________________________________________________________________________________________

______OPERATIVE NOTES _______RADIOLOGY REPORTS ________ENTIRE CHART _________ PHY THERAPY

______OFFICE NOTES

_______LAB/PATH REPORTS

________SPECIFIC INJURY________________________________

_____ I do ____ I do NOT

authorize release of information related to AIDS (Acquired Immunodeficiency

Syndrome) or HIV (Human Immunodeficiency Virus) Infection, psychiatric care

and/or psychological assessment, and treatment for alcohol and/or drug abuse.

INFORMATION

_______________________________________________________

RELEASED TO:

Name of Company/Agency/Facility/Person

______________________________________________________

Street address

______________________________________________________

City, state, zip

_______ e-delivery available to patient’s personal email, must complete additional form available from TCOA

PURPOSE OF DISCLOSURE:

______REFERRAL TO SPECIALIST ______INSURANCE

______WORKERS COMP ______LEAVING PRACTICE

______LEGAL INVESTIGATION

______DISABILITY DETERMINATION ______PERSONAL

______RELOCATION/MOVING

OTHER (SPECIFY)______________________________________________________________________________________________________

Please provide preferred telephone number in the event we need to contact you: _______________________________

I hereby authorize disclosure of the health information for the above named patient. This authorization is valid for 12 months from the date of signature.

I understand that I may cancel this request with written notification but that it will not effect any information released prior to notification of

cancellation. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it,

and would then no longer be protected by federal regulations. I understand that the medical provider to whom this authorization is furnished may not

condition its treatment of me on whether or not I sign the authorization.

NOTE: HEALTHPORT WILL PROVIDE ONE COPY OF RECORDS FOR PERSONAL USE, OR CONTINUING

CARE AT NO CHARGE. RECORDS WILL BE SENT BY STANDARD MAIL. HEALTHPORT DOES NOT FAX.

IF APPLICABLE, VA STATE RATES APPLY. PGS 1-50, $0.50 EACH, PGS 51+ $0.25 EACH, PLUS POSTAGE.

______________________________________________________

________________________

Signature of individual or guardian or

Date

Personal Representative of patient’s estate Power of Attorney Must Be Attached

MEDICAL INFORMATION RELEASED BY HEALTHPORT

ENTIRE_______ LAB_________