OrthoNeuro
For every motion in life.
Authorization for Disclosure of Health Information
PLEASE FAX TO: MEDICAL RECORDS 614-818-7724
I hereby authorize: __________________________________ to release medical information from the records of
Patient’s Name: _________________________________ D.O.B.: _____/_____/______ SS#: _____-_____-______
Patient’s Street Address: _______________________________________________________________________
City: _________________________ State: ______________ Zip Code: __________________
Date(s) of Treatment Requested: _________________________________________________________________
Information to be disclosed (check all applicable items to be released):
☐ ER Record ☐Progress Note ☐Treatment Plans ☐EKG/ECG ☐Consultations ☐Therapy Notes
☐ X-Rays Reports ☐Medication Records ☐History & Physical ☐Lab Reports ☐Tests ☐Operative Reports
☐ Other (please specify):___________________________________________________________________________
Purpose Or Need For The Disclosure Is:
☐Continued Medical Care ☐Insurance ☐Legal ☐Patient’s Own Use ☐Other____________________________
The Information May Be Disclosed To:
Recipient’s Name: _____________________________________________________________________
Street Address: _______________________________________________________________________
City: _____________________________________ State: __________________ Zip Code:__________
Phone #:__________________________________ Fax: _____________________________________
My refusal to sign this form will not adversely affect my ability to receive health care services, reimbursement for services enrollment
in a health plan or my eligibility for health benefits. However, information will not be released to the above indicated recipient
without my signature.
I acknowledge that the information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no
longer protected by Federal Law.
I have the right to revoke this authorization by written notice to the Healthcare Provider listed above. I understand that actions taken
in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires on: _______________________ or upon the following event: _______________________
(Date)
(If no date or event is specified, this authorization will expire in 60 days from the date of signature).
Fees: I understand and agree that there may be costs associated with this request in compliance with State copying laws.
____________________________________________________ ____________________________
(Signature of Patient or Personal Representative*) (Date of Signature)
*If signed by a personal representative, a description of the representative’s authority to act is as follows:
☐Parent ☐Legal Guardian ☐Health Care Power of Attorney
☐Administrator ☐Executor of Estate ☐Next of Kin ☐Beneficiary
I understand that the information in my medical record may include information relating to treatment of drug or alcohol abuse, mental
health, sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), AIDS related complex (ARC) and/or human
immunodeficiency virus (HIV).
click to sign
signature
click to edit
![]()
