Authorization To Release Medical Records

Patient Authorization To Release Medical Records

Patient Name

First, Last

Date

I hereby authorize Omnicare Medical Group Please Select Location you will be seen in.

36 Newark Ave, Suite 300 Belleville, NJ 07109 310 Central AVe, Suite 100 East Orange, NJ 07018 155 Prospect Ave, Suite 108 West Orange, NJ 07052 !40 Sylvan Ave, Suite 213 Englewood Cliffs, NJ 07632

To Release Information from the records of:

Patient Name

Patient Date of Birth

This medical information may be used by Omnicare Medical Group for medical treatment, consultations, billing, claims payments or other purposes as I may direct. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by Federal or State Law.

Do you understand the following statement and wish to authorize this request? Please check one

YES NO

Electronic Signature

Please Type your full name as your electronic signature to verify you understand the above statement and wish to proceed with the authorization.

Date of Signature

Your information will be encrypted.