Release of Medical Information

 

 

AURHORIZATION FOR THE USE OR DISCLOSURE OF HEALTH INFORMATION

          Standard" release of information(includes typed dictation and therapy notes)

          Specific information from the chart which includes:

          X-ray(S):

          Information necessary for the completion of FMLA and/or Disability documents.

 

I hereby request Tucson Shoulder Elbow + Hand, PC to make the use or disclose my protected Health Information to the following person(s) or institution(s) for FMLA and/or Document completion:

         Name/Institution:

         Address:

         Fax number:

 

The specific person or group of people or authorized to use disclose my protected Health information includes any health care provider and/or employee of Tucson Shoulder Elbow + Hand PC.

 

This authorization will expire 60 days from signing, unless an earlier date is indicated:

 

I understand that I have the right to revoke this authorization, if the revocation is writing, except if

             Tucson shoulder Elbow & Hand PC has taken in reliance upon this authorization;

             or , if this was given as a condition of obtaining insurance coverage, other law provides that the Insurance.

 

I understand that I may revoke this authorization by sending a written request to:

          Tucson Shoulder Elbow + Hand PC
          PO Box 64368, Tucson, AZ 85728
          Attention to: RELEASE OF INFORMATION

 

I understand that my protected Health information that is used or disclosed under this authorization May be subject to redisclosure be the recipient, and the privacy of my protected Health information Will no longer be protected by the law.

 

By signing this authorization, I acknowledge that I have read and understand this authorization. Further, I authorized the use or disclosure of my protected Health information in accordance with the terms of this authorization. Please mail this form to the address listed in number (6) fax it to 520.639.9010 or email to MR@tusconhand.com (attention to: release of information).

 

______________________________________________ _____________________________________________

Signature

(Patient) Date Signature

(Authorized

Representative) Date

______________________________________________ Description

of

Authorized

Representative’s

Printed

Name

(Patient)

authority

to

sign

for

the

patient:_____________________

_____________________

____________________ _____________________________________________

Patient’s

telephone

#

Patient’s

Date

of

Birth

__________________________________________________

Signature

(Witness)