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Home
About Us
Services
Contact Us
Patient Resources
Make A Payment
Multimedia
Preparing for surgery
Useful Links
General Surgery FAQ’s
Bariatric Surgery FAQ’s
Forms
New Patients
Physicians Referral
Medical Records Release
Bariatric Inquiry Form
Bariatric Packet
Home
About Us
Services
Contact Us
Patient Resources
Make A Payment
Multimedia
Preparing for surgery
Useful Links
General Surgery FAQ’s
Bariatric Surgery FAQ’s
Forms
New Patients
Physicians Referral
Medical Records Release
Bariatric Inquiry Form
Bariatric Packet
Menu
Home
About Us
Services
Contact Us
Patient Resources
Make A Payment
Multimedia
Preparing for surgery
Useful Links
General Surgery FAQ’s
Bariatric Surgery FAQ’s
Forms
New Patients
Physicians Referral
Medical Records Release
Bariatric Inquiry Form
Bariatric Packet
AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
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Patient Name:
Date of Birth:
Patient Address:
SSN:
By signing below, you hereby authorize us to use or disclose information about yourself (or another person for whom you have the authority to sign) that is protected under federal law, for the sole purpose and time period described below. You may refuse to sign this authorization. Subject to certain exceptions, you have the right to inspect and copy the protected health information
2. What information is to be disclosed? Information to be used or disclosed (must be identified in a specific and meaningful fashion); and purpose of the use and disclosure: Check all appropriate:
Entire record
Op notes
Billing records
Specific other
Information that may not be used or disclosed:
No restrictions
Or specify here:
3. Who may request disclosure? The name or other specific identification of the person(s), or class of persons, authorized to make the requested use or disclosure: (Check all that apply)
Myself only
Immediate blood/legal family members
Emergency contacts I have indicated
Other
Specify:
4. Who is to receive the requested information? The name or other specific identification of the person(s), or class of persons, to whom the Practice may make the requested use or disclosure: Enter name, phone number, fax and other information about recipient
Recipient:
5. Expiration date or an expiration event (must relate to the individual or the purpose of the use or disclosure): Check one:
12 months from the date of this Authorization
The duration of my current episode of care from this provider
Other
Specify:
This information about you is protected under federal law, and you have the right to revoke this authorization in writing. Please be advised, however that any revocation will be effective only to the extent we have not already taken action in reliance on your authorization. By signing below, you recognize that the protected health information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient of this disclosure and may no longer be protected under federal law. We will not condition treatment based on your authorization. You may refuse to sign the authorization. (Please print and sign and date in ink).
Patient Signature or Personal Representative:
Date:
Submit
