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:
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______ I understand that this information will expire only when revoked by the patient.
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I understand that I may revoke this authorization at any time by notifying in writing the above named Physician
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I understand that this authorization is voluntary
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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
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I understand that my treatment cannot be conditioned on whether I sign this authorization
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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)