AUTHORIZATION TO OBTAIN & DISCLOSE HEALTH INFORMATION I authorize the use or disclosure of the individual’s health information named below to be used or disclosed as follows: Patient Name: Alias or Other Names Used: Date of Birth: Email Address: Please OBTAIN information FROM the following: Name & Title of Provider/Organization Name: Street Address/Fax: City, State, Zip: Please SEND my health information TO: Name & Title of Provider/Organization Name: Street Address/Fax: City, State, Zip: For the purpose of: Patient Care Self/Personal Records Other: Description of Nature of Information to Be Used and/or Disclosed: Most recent 2yrs of records Clinician office notes History & Physical Exams X-ray & imaging reports Consultations Lab reports All Clinic records Billing statements Records for the following dates of treatment: Other (specify): List specific dates of records to be released: The following (*) must be initialed by the patient to be included: Please enter your initials: * HIV/AIDS related information and/or records * Mental Health information * Psychotherapy notes * Genetic Testing information ** Drug/Alcohol information **Federal regulation requires a description of how much and what kind of information will be disclosed. DURATION / RESTRICTIONS / RIGHTS DURATION: This authorization shall begin immediately and remain in effect until notified otherwise. RESTRICTIONS: I understand that the information released may be subject to re-disclosure by the recipient and may no longer be protected by privacy laws or regulations. RIGHTS: I understand that I may refuse to sign this authorization and that my refusal to sign may not affect my ability to obtain treatment. I may inspect or copy any information to be used and/or disclosed under this authorization in accordance with organizational policy and Spinal Diagnostics has up to 30 days to comply with my written request. I understand that I have the right to revoke this authorization by sending a written statement to the clinic manager of the disclosing location listed above. My revocation will be effective upon receipt, but will not be effective to the extent that this organization has taken action in reliance upon this authorization. Authorization Signature of Patient or Legal Representative: Clear Signature Date: (automatically added) If signed by legal representative, name & relationship to patient: Submit Form
