• AUTHORIZATION TO OBTAIN, RELEASE, OR REVIEW PROTECTED HEALTH INFORMATION (PHI)

  • Patient Information

  • I,         hereby authorize Soleil Surgical LLC To:

  • I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing. I understand that the revocation will NOT apply to insurance company when the law provides my insurer with the right to contest a claim under my policy. I understand that any disclosure of information carries with it the potential for any unauthorized disclosure and information may not be protected by federal confidentiality rules. If I have questions about disclosures of my health insurance, I can contact the office at (407) 343-4983. The facility, its employees, officers and physicians are hereby released from any legal responsibility of liability of the above information to the extent indicated and authorized herein. I also understand that this authorization expires within 1 (One) year of signature.

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