Medical Records Release Authorization from OA

Medical Records Release Authorization

Please use this form in order to provide Orthopedic Associates records to an outside company or person.
Patient Name *
Patient Date of Birth *

Month Day Year
Date
Date of Appointment *

Month Day Year
Date
Time of Appointment *

: Hour Minutes AM/PM Option
Patient Phone Number *

Area Code Phone Number
Upon presentation of this authorization you are requested to provide the records outlined below to:
Person/Company Receiving Records *
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Fax *
Records will be sent from

Orthopedic Assocaites of Flower Mound and Denton
5000 Long Prairie Road, Suite 100
Flower Mound, TX 75028

Phone: (972)420-1776
Fax: (214)222-6660
Dates of Service to Be Transferred *

Please provide a complete copy of my file for all dates of service Please provider a completely copy of my file for service in a specific date range
Date Start *

Month Day Year
Date
Date End *

Month Day Year
Date
Records to be Released *

All Medical Records (Does not include imaging or billing) Operative Report Radiology Reports History & Physical (Visit notes) Lab/Pathology Reports Images on Disk Itemized Billing
Purpose for Disclosure *

Disability Referring Physician Insurance Patient Request Attorney
Please indicate your acceptance by checking the following boxes:
*

I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken inreliance upon this authorization (45 CFR §164.508(c)(2)(i)).
*

I understand that treatment or payment cannot be conditioned on my signing this authorization, except in certaincircumstances such as for participation in research programs, or authorization of the release of testing results for preemployment purposes (45 CFR § 164.508(c)(2)(ii)).
*

I understand that my records are confidential and cannot be disclosed without my written authorization except whenotherwise permitted by law. Information used or disclosed pursuant to this authorization may be subject to redisclosure bythe recipient and no longer protected. I understand that the specified information to be released may include, but is notlimited to: history, diagnosis, and/or treatment of drug or alcohol abuse, mental illness, or communicable disease, includingHuman Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) (45 CFR § 164.508(c)(2)(iii)).
Today's Date

Month Day Year
Date
This authorization will expire One Hundred Eighty (180) days from the date of my signature unless I revoke the authorization prior to that time.

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