Authorization for Medical Records Release

John J. Park M.D, Slawomir J. Marecik M.D, Kunal Kochar M.D.

1550 N. Northwest Highway, Suite 107 Park Ridge, IL 60068 Phone: (847)759-1110 Ext: 229 Fax: (847)759-8273

Authorization for Release of Confidential Health Information

I, Name of Patient or Authorized Agent*
hereby authorize LM Prasad MD SC
to release to: Name of Health Care Facility, Physician, Agency, etc.*
Street Address*      City*   State*   Zip*
the following information contained in the patient record of
   Patient's Name* born   Date*
residing at   Street Address*      City*   State*   Zip*    :

Please select the information to be released:*

The entire medical record, including mental health treatment, alcoholism treatment, drug abuse treatment, and HIV / AIDS recordsX-Ray ReportsOperative NotesLaboratoryEKG ReportsOther

The above information for the following period of time shall be released from Date* to Date*

The purpose(s) of the authorization is (are)*

I understand that I have the right to inspect and copy the information I have authorized to be disclosed by the authorization. In the event I refuse to authorize the release of the above-described information, I understand that it will not be disclosed, except as provided by law.
I understand that the practice may not condition treatment on whether I sign this authorization, except when the provision of health care is solely for the purpose of creating protected health information for disclosure to a third party.
I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by law.
I understand that this authorization is valid until it expires unless revoked before that.
I understand that I may revoke this authorization at any time by giving written notice to the physician of my desire to do so. I also understand that I will not be able to revoke this authorization in cases where the physician has already relied on it to use or disclose my health information. Written revocation must be sent to the physician’s office. Absent such written revocation, this authorization for Release of Confidential Health Information will terminate on: Date

Signature*

Date

If you are not the patient, please specify your relationship to the patient