ALL RECORDS REQUESTS WILL TAKE APPROXIMATELY 5 BUSINESS DAYS

Choose an office: *

Please select an office.

Patient First Name

Please complete this field.

Patient Last Name

Please complete this field.

Address

Please complete this field.

Birthdate

Please complete this field.

Patient's Phone Number:

Please complete this field.

I hereby authorize the above entity to release information from my medical record to:

Patient

Doctor/Medical Provider

Insurance Co

Other

If Other, please specify:

Please complete this field.

Name of Doctor, Hospital, Insurance Company or Other Agency or Person to Whom the Information will be Released

Please complete this field.

Address of Receiving Party

Please complete this field.

Telephone Number:

Please complete this field.

Fax Number:

Please complete this field.

For the purpose of:

Continuation of Medical Treatment

Payment of Bill

Worker’s Compensation

Education

Legal Purposes

Insurance Purposes

At the Request of the Patient or the Patient’s Legal Representative for personal access

Other

Other (specify):

Please complete this field.

Information to be released is for the time period from:

Please complete this field.

SPECIFIC INFORMATION TO BE RELEASED:

EMG Reports

Laboratory Reports

MRI Report

Operative Reports

X-Ray Reports

Itemized Bill

MRI Copies

OAA Office Notes

X-Ray Copies

Other

If other, please specify:

Please complete this field.

I understand that this authorization is revocable by me, in writing, at any time, except to the extent that action has been taken in reliance on it. I will contact the above entity(s) immediately if I wish to revoke this authorization. As described in the Notice of Privacy Practices for the above entity(s), I may request such Notice of Privacy Practices for my ease of reference. I also understand that this consent will expire one year after the date of signature. I understand that the information released may be re-released by the recipient and may no longer be protected by HIPAA (Federal regulations). *Copy of Records to be Picked Up by Patient Will Only be Available for 90 Days

AUTHORIZATION SIGNATURES

NOTE: IF PATIENT IS A MINOR THE PARENT/GUARDIAN MUST SIGN (Excluding exceptions permitted by PA & Federal Law)

Date

Please complete this field.

Patient Signature

Please complete this field.

Patient Name (Printed):

Please complete this field.

If patient is unable to sign authorization form because of physical condition or age, complete the following:

Patient is a minor or patient is unable to sign authorization because:

Please complete this field.

Date

Please complete this field.

Signature

Please complete this field.

Relationship

Please complete this field.

Print/Type Name

Please complete this field.

Hurt or in Pain? 24/7/365 Orthopedic Experts in the Palm of your HandDOWNLOAD NOW!

RELEASE OF MEDICAL INFORMATION

AUTHORIZATION SIGNATURES

AUTHORIZATION SIGNATURES

If patient is unable to sign authorization form because of physical condition or age, complete the following:

If patient is unable to sign authorization form because of physical condition or age, complete the following: