Authorization for Disclosure of Protected Health Information (PHI)

I hereby authorize the use or disclosure of protected health information (PHI) as follows:

Patient name:   SSN:  

Previous, Maiden or other Name:   Date of Birth: //

Type of use or disclosure:   

Copies of medical records     Onsite review of records     Release permitting staff to verbally discuss care with others. Please list nature or type of discussions, name(s) of individuals and/or relationship(s) with patient:

    Other:

Method of delivery:      Mail Records       Fax Records to:        Call for pick up     

Information to be disclosed: 

Entire Record (Including, but not limited to, psychiatric/mental health information, sexual transmitted disease, HIV/AIDS, Sickle Cell Anemia, alcohol & drug abuse treatment and physical/sexual abuse).    Include copies of films (Cost is $ per film)

Other, (please specify):

Special Authorization: I authorize the release of information pertaining to alcohol and drug related diagnosis and treatment, consultation and/or treatment for mental health or psychiatric disorders, and information specific to AIDS, HIV and Sickle Cell Anemia. This special authorization is subject to the confidentiality provisions of Federal Statutes 21U.S.C.1175, 42U.S.C.4582 and regulations 42 CFR, Part 2 which prohibit any further disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.

Purpose of the disclosure: 

Personal use at the request of the patient     Continuing medical treatment     Legal proceedings     Insurance related    

Employment related purposes     Other

Date(s) of service:  All dates of service; or  From   to  

I understand:

·          I may revoke this authorization at any time, in writing, except that my revocation will not apply to information that has already been released in response to this authorization. This authorization may be revoked by submitting a written, dated and signed notice of revocation to the facility releasing this information. If not revoked, this authorization is valid until it expires 1 year from the date signed below or until the following date, event, or condition:

·          I understand that once this protected health information is used or disclosed pursuant to this authorization, privacy laws may not protect the information and it may be re-disclosed by the party who receives these records.

·          I have the right to inspect the health information to be released and I may refuse to sign this authorization.

·          I understand that treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this Authorization.

·          I hereby release Neurosurgical & Spinal Surgery Associates, P.C. and its affiliates, employees, officers and physicians from all legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

Signature of patient, parent/guardian or legal representative                                                     Date signed

Street Address                                                                                                          City/State/Zip

Relationship, if NOT the patient

Signature of the patient is required for all patients 18 years of age or older. A parent or legal guardian may provide the authorizing signature if the patient is a minor. It the patient is deceased, the next of kin, administrator, or executor of the estate may sign the authorization.                                         

                                                                                                                                                                                                                                                                                                                                                          (6/04)

(© 8/24/07)