Release

In: Business and Management

Submitted By cicelykendrick
Words 306
Pages 2
This form is used to release info “ TO” SC OBGYN
AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
____________________________________ ___________________________________________________
(Patient’s Full Name at Time of Treatment) (Patient’s Address, City, State, & Zip Code)

______________
(Chart #)

__________________
(Patient’s Date of Birth)

________________________
(Patient’s Social Security #) (Purpose of Release)

(_____) __________________
(Patient’s Telephone #)

______________________
(Date(s) of Treatment)

________________________________________________________________

I AUTHORIZE

_________________________________________________
(Releasing Facility’s or Provider’s Name)

_________________________________________________
( Address, City, State, & Zip Code)

to RELEASE my health information

TO:

South Carolina Ob-Gyn Associates, P.A. 1333 Taylor Street, Suite 2-D Columbia, SC 29201 ( SECURE FAX # 803-799-1635 )

INFORMATION TO BE RELEASED: (Please check all that apply) ALL Medical Information Diagnosis List / Patient Identification Laboratory Report(s) (type?) ________________ Physician Dictation (type?) __________________ Office Notes (type?) _________________________ Mammogram Report(s) Radiology Reports _________________________ Billing Info (type?) ________________________ Other ____________________________________ =========================================================== 1.) I understand that if my records contain documentation of alcohol abuse, psychiatric condition, drug abuse, or communicable diseases, this information will be released as part of my record. 2.) I understand that if the person or entity receiving this information is not covered by federal privacy regulations, this information will no longer be protected and may be re-disclosed. 3.) I understand that I may revoke this authorization at…...

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