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Endicott Podiatrist | Endicott Authorization For Release of Health Information | NY | Mario G. Silvestri, DPM |

Mario G. Silvestri DPM, PC

Podiatric Medicine & Surgery

1003 Monroe Street

Endicott, NY 13760

607-484-3668

Office Hours
Monday:8:00am - 5:00pm
Tuesday:8:00am - 5:00pm
Wednesday:8:00am - 4:30pm
Thursday:8:00am - 5:00pm
Friday:8:00am - 4:30pm


Authorization For Release of Health Information To Designated Party



Patient Name:_______________________________


Physician Name: Mario G. Silvestri, DPM


Designated Party:________________________ Designated Party: _______________________


Relationship to Patient:____________________ Relationship to Patient: ___________________


Address :_______________________________ Address: _______________________________


Phone: _______________________________ Phone: ________________________________


The information will be used or disclosed for the following purposes:


_____ At the request of the individual _____ Other ____________________________


This Authorization grants PERMISSION to the Designated Party (ies) named above to:


_____ have access to my medical record information


_____ have access to my billing and insurance information


_____ have access to any test results


_____ make or confirm appointments


_____ other, please specify ___________________________________________________________


I authorize Mario G. Silvestri, DPM, PC to use and disclose my health information as described in this authorization.


The patient or the patient's representative must read and initial the following statement:


  • ______ I understand that this information will expire only when revoked by the patient.


  • I understand that I may revoke this authorization at any time by notifying in writing the above named Physician

  • I understand that this authorization is voluntary

  • I understand that once this information is released to the Designated Party (ies), the release information may no longer be protected by federal privacy regulations

  • I understand that my treatment cannot be conditioned on whether I sign this authorization

  • I have been offered a copy of this office's Notice of Privacy Practices




_______________________________________ _________________________

Signature of patient or patient's representative Date

(Form MUST be completed before signing or will not be valid)




 

 
 
 
 
Endicott Podiatrist Mario G. Silvestri, DPM is a poidiatry office providing Authorization For Release of Health Information, orthopedic, pain, diabetes, bunions and much more in Endicott, NY. We also do Achilles Tendonitis, Allergic Contact Dermatitis , Athlete's Foot, Brachymetatarsia, Bunions, Calluses, Diabetic Foot Care, Flatfoot (Fallen Arches), Ganglions, Haglund's Deformity, Hallux Rigidus, Hammertoes, Heel Pain/Fasciitis, Infections, Injuries, Ingrown Toenails, Metatarsalgia, Morton's Neuroma, Onychomycosis, Osteoarthritis, Pediatric Foot Care, Plantar Warts, Plantar Fasciitis, Posterior Tibial Dysfunction, Rheumatoid Arthritis, Running Injuries, Sesamoiditis, Sprains/Strains, Tarsal Tunnel Syndrome, Taylor's Bunion, Tendonitis, Toe Deformities, Xerosis and all work related in the 13760 area and surrounding areas in Endicott

Mario G. Silvestri, Dpm