AUTHORIZATION TO DISCLOSE

I understand that if the person (s) or entity (ies) that receives the information is not a health care provider or a health plan covered by federal privacy regulations, the information described below is no longer protected by those regulations.

This authorization may be revoked at any time, and must be in writing, signed by me or on my behalf, and delivered to the address at the bottom of this form. This shall remain in effect from the date of signing until rescinded by patient or on my behalf.

AUTHORIZATION TO DISCLOSE MEDICAL INFORMATION & BILLING INFORMATION REGARDING PATIENT BELOW

This authorization must be written, dated and signed by patient or by a person authorized by law to give the authorization.

I authorize Medford Foot and Ankle Clinic Staff to release specific health information regarding my care and treatment; and to discuss billing and accounting inquiries on my behalf. To the following recipient (s):

DISCLAIMER: 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.