Authorization for Disclosure of PHI

Fill out and submit the form below to allow us to release your medical records.

Authorization for Disclosure of PHI

"*" indicates required fields

About the Patient

Patient Name*

Phone*

Date of birth*

Street address*

City*

State*

Zip*

Care Details

I hereby authorize Midtown Pain and Spine to release information from the medical records of the patient listed above (To Practice, To Me).

Choose one:*

To practice

To me

Practice details

Office Name

Phone

Fax

Send the information to

My Email

My Fax Number

My Mailing Address

Street Address City State ZIP / Postal Code

Other details

For treatment dates*

All dates

Specific dates (enter those below)

Specific treatment dates*

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

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*

Date*