AUTHORIZATION FOR RELEASE OF INFORMATION

TRIANGLE FOOT AND ANKLE SPECIALIST, P.C.
217 Davis St.
Southern Pines, NC 28387.

I hereby authorize Triangle Foot and Ankle Specialist to disclose my protected health information as described below. I understand that this authorization is voluntary. I understand that the information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. I understand that I may see and copy the information described on this form if I ask for it, and that I will receive a copy of this form after I sign it. I understand that I may revoke this authorization at any time by giving notice in writing at the address found above, but if I do it will not affect any actions taken before receipt of my revocation.

I understand that my treatment will not be conditioned on whether I provide authorization for the requested use or disclosure except (1) if my treatment is related to research, or (2) health care services are provided to me solely for the purpose of creating protected health information for disclosure to a third party.

Patient Name:

Date of birth:

Persons / Organizations to receive the information:

The Specific information to be released / disclosed is specified below:

Please select:

Complete Medical Record

Operative Reports

Progress Notes

Laboratory

X-rays

Billing and Claim Records

Other

If other, please specify:

This information is to be used / disclosed for the following purpose(s) only:

(no purpose need be stated if the request is made by the patient and the patient does not wish to state the purpose).

This authorization will expire on

Date:

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

Signature of patient or patient’s representative:

(Form MUST be completed before signing)

Date:

Name of patient’s representative (if applicable):

Relationship to the patient (if applicable):

YOU ARE ENTITLED TO A COPY OF THIS DOCUMENT

Your information will be encrypted.

AUTHORIZATION FOR RELEASE OF INFORMATION

The Specific information to be released / disclosed is specified below:

*YOU ARE ENTITLED TO A COPY OF THIS DOCUMENT*

YOU ARE ENTITLED TO A COPY OF THIS DOCUMENT