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Authorization to Disclose Health Information

Patient Information

Patient First Name *

Patient Last Name *

Date of Birth *

Phone Number *

Patient Address *

City *

State *

Zip Code *

Other Names During Treatment *

RELEASE INFORMATION

Please complete this section and check mark next to the appropriate to/from box in order for the request to be processed:* Release Information to ORRequest Information from

Name/Facility *

Attention *

Street Address *

City *

State *

Zip Code *

Fax Number *

Phone *

Purpose of Request:* PersonalTreatmentLegalInsuranceDisabilityMilitary/VA

Transfer/Reason

Other

INFORMATION TO BE RELEASED

Please provide information in my medical records for dates:

From *

To *

Place a check mark next to the requested records:* Chart SummaryOffice Visit NotesImages CDMRIXRPhysical Therapy NotesLaboratory TestsImaging ReportsEntire Medical RecordEntire Medical Record, including outside documentsGenetic Testing/StudiesPhone NotesOther

Other *

FORM OF RECORDS

FORM OF RECORDS:* Records on PaperRecords on CDRecords via eDelivery, requires email address

Email Address *

AUTHORIZATION TO RELEASE PROTECTED

I want information on Mental Health to be released:* I DoI Do Not

Intial Each Line Below *

I want information on HIV Tests and Related information to be released:* I DoI Do Not

Intial Each Line Below *

I want information about Alcohol and/or Substance Abuse released:* I DoI Do Not

Intial Each Line Below *

I want information about Communicable Diseases released:* I DoI Do Not

Intial Each Line Below *

Please confirm that you have put a checkmark and initialed all the protected information categories above regardless if they are applicable or not. If the form is incomplete, or if protected information is not released, we may be unable to fulfill this request.

This authorization will expire 12 months from the date is signed. I understand that I may revoke this authorization at any time by notifying The CORE Institute in writing to: The Center for Bone & Joint Surgery 10131 Forest Hill Blvd Ste 230 Wellington, FL 33414 or via fax to 561.753.8635. If I do, it will not have any effect on the actions The Center for Bone & Joint Surgery took before it received the revocation.
I understand that under the applicable law the information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and is no longer subject to the protections of the privacy standard.
The Center for Bone & Joint Surgery may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization.
I understand that in compliance with state laws pertaining to record copies, I may be charged a reasonable fee.
I understand that I may inspect or copy the information that is used or disclosed.

Patient Signature *

Date *

Signature of Parent or Legal Guardian *

Date *

Please Note: Any information submitted using this form is transmitted securely and held in the strictest of confidence, protecting your privacy.

* = Input is required

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