Authorization to Disclose Health Information

Patient Information

RELEASE INFORMATION

INFORMATION TO BE RELEASED

Please provide information in my medical records for dates:

FORM OF RECORDS

AUTHORIZATION TO RELEASE PROTECTED

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.