testing 20 June Step 5 - Amarillo Bone & Joint Clinic, PLLC

Authorization for the Disclosure of Health Information

Patient Name

Date of Birth

Social Security Number

Telephone Number

Address

City

State

Zip

I hereby authorize and request Amarillo Bone & Joint Clinic, LLP to

provide to

receive from

I hereby authorize and request Amarillo Bone & Joint Clinic, LLP to

Specify date(s) of Encounter(s)/Hospitalization(s)

The type and amount of information to be used or disclosed is as follows:

The type and amount of information to be used or disclosed is as follows:

Complete Medical Record

Physician’s Office Progress Notes

Photographs, Videotapes, Digital or other images

The type and amount of information to be used or disclosed is as follows:

History & Physical

X-Ray Film(s)

The type and amount of information to be used or disclosed is as follows:

Operative Report

Problem List Discharge Summary

Other

The type and amount of information to be used or disclosed is as follows Other reason

with regard to

(Patient Name)

medical/hospital records for the purpose of:

Continuity of Care

Billing and Payment of Bill

Other

medical/hospital records for the purpose of (Other)

I understand that this authorization can be revoked, in writing, at any time except to the extent that disclosure made in good faith has already occurred in reliance upon this authorization. This authorization shall expire one year after the date appearing below except for payment of all claims at which time this authorization may be in force greater than one year.

This authorization is for full disclosure of all health data which may include any information related to care for my impairment(s) information about how my impairment(s) affects my ability to complete tasks and activities of daily living, information about how my impairment(s) affect my ability to work; and/or related to drug, alcohol, mental health, psychiatric conditions, and/or sexually transmitted disease, Sickle Cell anemia, including AIDS/HIV information [42 CFR part 2]. Such records will be disclosed unless you specify information that you wish to be excluded.

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form to ensure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in 45 CFR 164.524. If I have questions about disclosure of my health information, I can contact Amarillo Bone & Joint Clinic, LLP.

Facsimile transmission of this form will be deemed as having the same force and effect as an original. The risks associated with the use of facsimile transmission are understood.

This form

was read BY me

was read TO me.

I have been offered the opportunity to ask questions about this form, and I fully understand its contents and meaning. All blanks were filled in before the form was signed by me.

Patient or Authorized Representative Signature

Date

If signed by Legal Representative, Relationship to Patient

Witness Signature

Date

Interpreter's Statement (if Interpreter assisted):

I have translated the information presented orally to the patient by: (Employee's Name)

I have also read the Authorization for Disclosure of Health Information Form to: (Patient Name)

in (language)

Signature of Interpreter

Date