AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION TO THIRD PARTY PURSUANT TO HIPAA
This authorization indicates a disclosure of information pertaining to medical records and the release of official laboratory results/treatment to a third party for the intended medical reasons. I, the patient, allow Checkmate Health Strategies to release any/all results and reports from my pre-surgical testing to my medical doctor, surgeon, and/or the affiliates involved in my healthcare and sports medicine care plan.
I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.
I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form to only those agreed upon for the my care.