HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT INFORMATION
TO: ____________________________________________________________________
Name of Healthcare Provider/Physician/Facility/Medicare Contractor
_____________________________________________________________________
Street Address
______________________________________________________________________City, State and Zip Code
RE: Patient
Name:___________________________________________________________
Date of Birth: ______________________ Social Security Number:__________________
I authorize and request the disclosure of all protected information for the purpose of review and evaluation. I expressly request that the designated record custodian of all covered entities under the HIPPA identified above disclose full and complete protected medical information including the following:
____ All medical records, meaning every page in the record, including but not limited to: office notes, face sheets history and physical, consultation notes, impatient, outpatient and emergency room treatment, all clinical charts, reports, order sheets, progress notes, nurse’s notes, social worker records, clinic records, treatment plans, admission records, discharges summaries, requests for and reports of consultations, documents, correspondence, test results including laboratory, histology, cytology, pathology, radiology records and films including CT scan, MRI and MRA, statements, questionnaires/histories, correspondence, photographs, telephone messages and records received by other medical providers.
____ Complete Record ____ All Diagnostic Test Results ____ Pathology Report ____ Consultation ____ Lab Only ____ Therapy Records ____ Radiology Records ____ Operative Report ____ Progress Note(s) ____ Other (please specify)
I understand that this authorization extends to all or any part of the records designated above, which may include psychiatric information and/or genetic counseling/testing, and/or alcohol/drug abuse and/or AIDS (Acquired Immunodeficiency Syndromes), and/or include the result of an HIV test or the fact that an HIV test was performed. I expressly consent to the release of information as designated above. The authorization is valid and will not expire while I am a patient of GA ENT and Facial Plastics. I understand that this authorization is revocable upon written notice to the office where the original authorization is retained, except to the extent that action has already been taken on this authorization. I understand that my protected health information that is used or disclosed under this authorization may be subject to re-disclosure by the recipient and the privacy of my protected health information may no longer be protected by law. I further understand that GA ENT and Facial Plastics may not condition the provision of treatment, payment, enrollment in the health plan, or eligibility for benefits on the provision of this authorization.
_______________________________________________________ _______
Patient or Parent/Legal Guardian Signature Date
Office Use Only: ____ I wish to revoke this authorization.
Signature: _______________________ Date: _______________
