Asps Authorization To Release Medical Records printable pdf download

The Garramone Center

Charles E. Garramone, D.O.

Plastic & Reconstructive Surgery

4725 SW148th Ave, Suite 202,

Davie, FL 33330

954-752-7842

If you want to allow us to speak with anyone else regarding your appointments, financial payments,

scheduling, protected health information, etc, you must fill out this form completely and fax it to

(954) 473-2454 or email to

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS/PROTECTED HEALTH INFORMATIONThis

document must be signed by the patient or person authorized by law.

Name: ______________________________

Address: ________________________________

City: _______________ State: __________

Zip Code: _________________

________________

__________________

Date of Birth:

Social Security Number:

_______________________________________

Other identifying information if applicable (other names):

Transmission by facsimile (fax) or electronic means (email) is authorized by the signed patient to expedite transfer

of records.

I, ____________________________, hereby authorize Aesthetic Plastic Surgery Institute, PA and its

associates to discuss, release, or obtain the records identified on Exhibit A to this Authorization for Release of

Protected Health Information. I agree to be responsible for all photocopying charges associated with the

reproduction of such records.

This Authorization for Release of Protected Health Information applies only to the release of the records

identified on Exhibit A. Such records should be released or obtained from or to

[name and address of recipient] for the following purpose(s):

I understand that providing my authorization is voluntary. I need not sign this Authorization for Release of

Protected Health Information to continue to receive healthcare treatment Aesthetic Plastic Surgery Institute, PA

and its associates . I understand that I may revoke this authorization, in writing, at any time except to the extent

that disclosure was made prior to the time I revoked this authorization. I further understand that I may inspect and

receive copies of the information to be disclosed.

I understand that the health records and information disclosed, or some portion thereof, may be protected

by the Federal Health Insurance Portability and Accountability Act (“HIPAA”). I further understand that it is

possible that the information described above may be re-disclosed by the recipient and may no longer be

protected by HIPAA, and that all means of voice, fax, or email transmission may be unencrypted or not secure,

and Aesthetic Plastic Surgery Institute, PA and its associates are not responsible for unauthorized access

of protected health information while in transmission to the individual based on the individual's request.

Further, Aesthetic Plastic Surgery Institute, PA and its associates are not responsible for safeguarding

information once delivered to the individual. I further understand that my records may be protected under

state law and, if so, cannot be disclosed without my written consent unless otherwise provided for in the law

and/or regulations.

My signature below acknowledges that I have read, understand, and authorize the release of the

information described on Exhibit A.

[Name]

Date:

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Asps Authorization To Release Medical Records

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