AUTHORIZATION FOR RELEASE OF INFORMATION

Please correct the errors described below.

TRIANGLE FOOT AND ANKLE SPECIALIST, P.C.
1720 NW Maynard Rd.
Cary, NC 27513

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 the 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.

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

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

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.

(Form MUST be completed before signing)

*YOU ARE ENTITLED TO A COPY OF THIS DOCUMENT*

Your information will be encrypted.

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