Release of Information Form

AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH INFORMATION

PATIENT

Patient's Name:

Date of Birth

Other Names Used:

Driver’s License

Please Upload screenshot of your Driver’s License (Front & Back)

Add file

Please upload a file

Identification and Insurance Cards

Please Upload screenshot of your Identification and Insurance Cards (Front & Back)

Add file

Please upload a file

FROM

I request patient’s information be sent by:

Dr. David Chua

Dr. Maria Hernandez

Dr. Rajeev Nayar

Dr. Albert Saporta

Dr. Arun Verma

If "Another health care provider" is selected, please specify:

PROVIDE TO

Who do you want the patient information to be sent to?

Name

Phone Number

How do you want the medical information to be sent?

It will be picked up.

Fax

Mail

Other

If Fax is selected, please specify:

If Mail is selected, please specify address:

If Other is selected, please describe:

*Sending information by Fax increases privacy risks, as they involve increased risk of accidental disclosure. Information sent electronically may also be vulnerable to cyber-attack.

REQUESTED INFORMATION

Please check or describe the health information that you would like disclosed:

Complete Record

Discharge Summary

History & Physical Exams

Physician Reports

Radiology & Imaging Reports

Pathology Reports

Laboratory Results

Records for the following dates or treatment:

Please specify:

Other

Please specify:

Specific Sensitive Information needs to be initialed to be disclosed:

Mental/Behavioral Health Treatment

Drug/Alcohol Abuse

HIV/AIDS Information

STD Treatment

PURPOSE

Why are you requesting this disclosure?

Personal Use

Insurance

Second Opinion

Legal

Continuation of Care

Other

If Other is selected, please specify:

VALIDITY

Expiration: This authorization will expire one (1) year from the signature date, unless an alternative expiration date is provided here:

Revocation: An authorization may be revoked at any time by written notice to Summit Digestive & Liver Disease Specialists. Revocation is not effective until notice is received and is not effective regarding disclosures made before revocation and where authorization was obtained as a condition of insurance coverage.

PATIENT RIGHTS

I understand that: (1) I have a right to receive a copy of this signed authorization upon request; (2) I have a right to refuse to sign this authorization – Summit Digestive & Liver Disease Specialists may not condition treatment, payment, enrollment in a health plan or eligibility for health care benefits on a decision to sign this form; and (3) I have a right to inspect or copy my health information. I may arrange to inspect or copy information maintained by Summit Digestive & Liver Disease Specialists by contacting Health Information Management. I may be charged a reasonable fee for copying costs.

REQUESTOR

I authorize the disclosure of health information described above. Information released under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by Federal privacy standards, including HIPAA and the Privacy Act of 1974. A photo copy/fax of this form is as valid as the original.

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

Print Name:

Date

Relationship to Patient:

Self

Parent/Guardian

Legally Authorized Representative

Other

If Other is selected, please specify:

OFFICE USE ONLY

Verification Method:

Please select:

Priority