Authorization For Release Of Protected Health Information From Buffalo Medical Group printable pdf download

BUFFALO MEDICAL GROUP

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

FROM BUFFALO MEDICAL GROUP

I, ___________________________________

Date of Birth: _____________________________

Name (REQUIRED)

_____________________________________ Daytime Phone: ___________________________

_____________________________________ Social Security Number: _____________________

_____________________________________

______________________________________

Address (REQUIRED)

Authorize release of my protected health information (PHI):

FROM:

TO:

Name:

Buffalo Medical Group

Name:

___________________________________

Address: Release of Information Department

295 Essjay Road

Address: ___________________________________

Williamsville, NY 14221

___________________________________

Fax # - 716-630-1251

_ _________________________________

I would prefer the following information to be disclosed: (REQUIRED-Please check all that apply):

___ All Medical Records (excluding imaging films)

Prefer:

Paper Copy ______ CD Copy _____

___ All Medical Records (including imaging films marked below) Prefer:

Paper Copy ______ CD Copy _____

___ Imaging films only (as marked below)

___ Mammography Films and Reports

___ Ultrasound CD and Reports

___ MRI CD and Reports

___ CT CD and Reports

___ X-Ray Films and Reports

___ All available previous films and reports

This authorization expires: _________________ (Unless otherwise stated, authorization expires six (6) months

from the date of authorized signature.)

I understand that I have the right to revoke this authorization at any time but that I must do so in writing. This

does not affect records sent out in reliance on this authorization prior to receiving the revocation request.

I want the following information to be disclosed: (REQUIRED-Please specify): ______________________

____________________________________________________________________________________

The purpose of this disclosure is: (REQUIRED-Please Specify):_________________________________

Please be aware that information disclosed pursuant to this authorization is subject to re-disclosure by the

recipient and is no longer protected by this organization.

___________________________________________

Signature of Patient or Representative (

)

REQUIRED

If Representative, authority on which acting for the patient: _____________________________________

Date: ________________________ (

) PATIENT SHOULD KEEP COPY OF THIS FORM

REQUIRED

“REQUIRED” fields must be completed for Release of Protected Health Information

Buffalo Medical Group, P.C. will not condition the provision of treatment on the provision of this authorization

Revised: 04/03/2014

Authorization For Release Of Protected Health Information From Buffalo Medical Group

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