AUTHORIZATION PROTECTED HEALTH INFORMATION (PHI)

AUTHORIZATION TO OBTAIN, RELEASE, OR REVIEW PROTECTED HEALTH INFORMATION (PHI)
Patient Information
Patient’s Name:

First Last Name
Mailing Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone:
Cell Phone:
Date of Birth:

Month Day Year
Social Security Number:
I, First Name Last Name hereby authorize Soleil Surgical LLC To:
Release Copies of ALL Medical Records To: Obtain ALL Medical Records From:
Facility Name:
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone:
Fax:
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.
Patient Signature:

Clear
Date:

Month Day Year
Should be Empty:

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