Patient Health History - Intake Form (Page 8 of 8) in pdf

Patient Health History - Intake Form Page 8

Pain Management Associates

305 West Grand Avenue Suite 500

Montvale, NJ 07645

Tel: 201-326-4777 Fax: 201-391-1196

This letter will authorize you to provide a copy, summary, or narrative of my medical records (as indicated by the

check mark(s) below) or to otherwise release confidential information. At this time I am requesting the following:

__________ Complete record

__________ Records of care from _____________________ to ________________ only

__________ Records of care concerning the following condition(s)

______________________________________________________________________________

__________ Other. Specify: ______________________________________________________

__________ Confer with other person orally about information in my medical record

to the following person(s):

_______________________________________________________________

Name

_______________________________________________________________

Street

_______________________________________________________________

City

State

ZIP

The reasons or purposes for this release of information are:

______________________________________________________________________________

I understand that you will provide this information within 15 business days from receipt of request, and you may

charge a fee for preparing and furnishing this information.

The fee is waived because the records are to be used for supporting an application for disability or other benefits or

assistance under Aid to Families with Dependent Children, Medicaid, Medicare, Supplemental Security Income, and

Federal Old-Age and Survivors Insurance. I have attached a statement which confirms that such an application or

appeal has been filed or is pending.

Signed:____________________________________________________ Date: ____________

(Patient or person legally authorized to consent on patient's behalf)

Patient Health History - Intake Form Page 8