Medical Records Authorization Form

Patient Last Name:

First Name:

SS#:

DOB:

Telephone:

I hereby authorize you to use or disclose the specific information described below, only for the purpose and recipient described below: (Specifically describe the information to be used or disclosed, including, but not limited to, meaningful descriptors such as: date of service, type of service provided, level of detail to be released, origin of information, etc.)

Recipient of Information:

Name of Entity / Provider

2140 West 68th Street, Suite 305 Hialeah, FL 33016-1815
Ph: (305) 822-4107
Fax: (305) 822-5086

This protected Health Information is being used disclosed for the following purposes:

Insurance

Continued Treatment

Legal

At the Request of patient or representative

Other

If you checked Other, please specify:

How would I like the records to be released?

Paper Copy Electronic Copy

(i.e., Email)

Fax Mailed Picked up by

If you selected Fax, please specify:

If you selected Picked up by, please specify:

This authorization shall be in force effect from the date signed below until (specify date) or (event that relates to the patient or the purpose of the use or disclosure) at which time this Authorization to use or disclose this protected health information exprires.

Specify date:

Event that relates to the patient or the purpose of the use or disclosure:

I understand that I have the right to revoke this Authorization, in writing, at any time by sending such written notification to Privacy Office at 2140 W 68th St, Suite 305, Hialeah, FL 33016. I understand that a revocation is not effective to the extent that Digestive Medicine Associates has relied on the use or disclosure of the protected health information.
I understand that information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.

I understand that I have the right to:

Inspect or copy the protected health information to be used or disclosed as permitted under federal law (or state law) To the extent the state law provides greater access rights.
Refuse to sign this Authorization The use or disclosure requested under this Authorization may result in direct or indirect remuneration to the Digestive Medicine Associates from a third party.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient or Personal Representative:

Date:

Description of Legal Representative's Authority:

Date:

Your information will be encrypted.

Medical Records Authorization Form

Digestive Medicines Associates, LLP