Authorization to Obtain & Disclose Health InformationPlease complete the form below. A signed PDF copy will be generated automatically and sent to you by email. Patient Name Date of Birth Alias or Other Names Used Email Address Please OBTAIN information FROM the following: Name & Title of Provider / Organization Street Address or Fax Number City / State / Zip Please SEND my health information TO: Name & Title of Provider / Organization Street Address or Fax Number City / State / Zip Purpose of Request Patient Care Self/Personal Records Other Description 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 Sensitive Information Requiring InitialsOnly complete initials below if you are authorizing release of any of the following categories. Initials HIV/AIDS related information and/or records Mental Health information Psychotherapy notes Genetic Testing information Drug / Alcohol informationNote: Federal regulation requires a description of how much and what kind of information will be disclosed.DURATION / RESTRICTIONS / RIGHTSDURATION: 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.AuthorizationPlease sign below. The date is added automatically when the PDF is generated. Clear Signature If signed by legal representative, name & relationship to patient Submit Form
