Authorization for Disclosure of PHI

Fill out and submit the form below to allow us to obtain your medical records. Alternatively, you may print the form (PDF version) to fill out and bring in person or mail to us.

Authorization for Disclosure of PHI

About the Patient

Patient Name(Required)

Medical Record #

Phone(Required)

Date of birth(Required)

Street address(Required)

City(Required)

State(Required)

Zip(Required)

Email(Required)

Care Details

Authorization

I hereby authorize the following (name, person, or organization) to release information from the medical records of the patient listed above to Dr. Thomas Weber, Midtown Pain and Spine Clinic.

Fax: (984) 272-3917 Phone: (984) 272-4028

For treatment dates(Required)

All dates

Specific dates (enter those below)

Specific treatment dates(Required)

For the following purpose: Medical Care (continuing care)(Required)

Entire record including, but not limited to diagnoses, lab and imaging results, and treatments.

Entire record excluding HIV & chemical dependency

Entire record excluding mental health records

Other

This authorization expires 180 days from the date signed below and covers only treatment(s) for the dates specified above.
I, the undersigned, have read the above and authorized the disclosure such information as herein contained. I have the right to revoke this authorization in writing at any time except to the extent that action has been taken in the reliance upon it. I understand that when this information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected. I hereby release and hold harmless the above named facility from all liability and damages resulting from the lawful release of my Protected Health Information.

Signature of patient/parent/guardian(Required)

Date(Required)

Holiday Office Hours Notice

Authorization for Disclosure of PHI