611 MRI Authorization for Release of Protected Health Information

611 MRI Authorization for Release of Protected Health Information (Part 2 of 2)
I authorize 611 MRI - located at 2950 Fairway Drive, Altoona, PA 16602 to use and disclose a copy of the specific health information described below regarding:
Patient Name:*

First NameLast Name
For Minors, Patient Representative's Name:

First NameLast Name
Patient DOB:*

MonthDayYear
Date
Phone Number:*
Please enter a valid phone number.
Records are requested for the purpose of clearance or diagnosis comparison for all scheduled studies at 611 MRI.
I am requesting information from the following facility(s):
Hospital/Clinic or Provider Name and Location*
Hospital/Clinic or Provider Name and Location
Hospital/Clinic or Provider Name and Location
Hospital/Clinic or Provider Name and Location
I am requesting information related to the following diagnosis or injury:*
Information to be disclosed (check all that apply):*

Diagnosis Reports: X-rays, MRI, CT, etc.BUN/Creatinine ResultsOrbit X-ray for MRI ClearanceOperative ReportOther
I understand the following:

-The health records will not be released or obtained by 61 I MRI/CT unless permission is provided for herein as evidence by the signature on this Authorization for Release of Protected Health Information (Authorization)

-That the release of my health record(s) will be for the purpose stated on this form, and only those items indicated to be released.

-That the health records released by the facility/person authorized above may possibly be re-disclosed by the facility/person that receives the record(s) and therefore (I) its staff/employees have no responsibility or liability as a result of the re-disclosure and (2) such information would no longer be protected by the Privacy Rule.

-That this information is in effect for a period of 1 year from the date of signature, unless a specified time frame is documented: however, no time frame specified shall go beyond one year from the date of signature.

-That I have the right to revoke this authorization form at any time by sending a written request to the entity where the authorization was processed.

-That my decision to revoke the authorization does not apply to any release of my health record(s) that may have taken place prior to the date of my request to revoke the Authorization.

-That my decision to revoke the authorization may result in my insurance company not being able to pay for my medical care and I may be liable for payment of the claim.

-That I am entitled to a copy of this complete Authorization form.
Signature of Patient, Parent, or Guardian:*

Clear
Please use a your mouse or finger to sign above.
Name*

First NameMiddle Initial or NameLast Name
DATE SIGNED:

MonthDayYear
Date
Should be Empty:

611 MRI Authorization for Release of Protected Health Information (Part 2 of 2)