By signing this authorization, I authorize Athens Spine Center (the “Practice”) to use and/or disclose certain protected health information (PHI) to or for the party or parties listed below.
What PHI may be used or disclosed:
This Authorization permits the Practice to use or disclose the following PHI:
appointment information, medical records, and billing information
Describe the specific purpose(s) for which you authorize the Practice use or disclose this PHI:
for the processing of workers compensation claims, authorizations and case management
To whom may the PHI be disclosed:[This may be inapplicable if Athens Spine Center is going to use the PHI for its own purposes and not disclose it to a third party.]
Entity Name: Workers’ Compensation Case Manager & Adjuster
This authorization will expire: one year from the date this form was completed