Authorization for Disclosure of Confidential Information

Requesting Physician
	G. Lance Miller, M.D.	Jennifer E. Trottman, M.D.	Samantha Nigh, PA-C
	Joseph P. Moore, M.D.	Leslie K. Walker, M.D.	Stephanie McCalman, PA-C
	Vicki C. Baker, M.D.	John L. Eckenrode, M.D.	Kristin Pickard, PA-C
	Joseph P. Lynch, M.D.	Paul E. Zorsky, M.D.	Lindsey Freeman, PA-C
	Ravikumar Vasireddy, M.D.

PATIENT NAME	DATE OF BIRTH	SOCIAL SECURITY NO.	ACCOUNT NUMBER

You may discuss my healthcare and billing issues with the following individuals:

	RELEASE TO:		OBTAIN FROM:

The information will be obtained, used, or disclosed for the following purpose(s) only:

Insurance

Continued treatment

At the request of the patient or patient’s representative

Other (Specify):

Legal

	Address	City	State	Zip Code

Information pertaining to medical care and treatment:
	All Medical Information about this patient
	Hospital Discharge Summary	Pertinent Laboratory	Complete Medical Record
	Consultations	X-Ray/Scan Reports	Surgical Pathology
	History and Physical	Other

I Understand:

I may revoke this authorization at any time, in writing, except revocation will not apply to information already used or disclosed in response to this authorization. I may revoke this document by presenting my written revocation as provided in the Notice of Privacy Practices. Unless revoked or otherwise indicated, the automatic expiration date will be one year from the date of signature or upon occurrence of the following event:
I release the entities listed above, their agents and employees from any liability in connection with the use or disclosure of the protected health information covered by this authorization. The entity authorized to disclose the information will not be compensated by the recipient for the disclosure.
Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected by federal law. However, the recipient may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality Requirements.
I have the right to inspect the health information to be released and I may refuse to sign this authorization.
Unless the purpose of this authorization is to determine payment of a claim for benefits, the requesting entity will not condition the provision of treatment or payment for my care on my signing this authorization.

The information authorized for release may include records which may indicate the presence of a communicable or non-communicable disease.

I further understand that my medical information may indicate that I have or have been treated for psychological or psychiatric conditions or substance abuse.

PATIENT'S SIGNATURE (IF PATIENT IS UNABLE TO SIGN, INDICATE REASON)

Date

PATIENT/GUARDIAN/OTHER (SPECIFY RELATIONSHIP TO PATIENT)

Date

Expiration Date of Authorization

Witness

Date

NOTICE OF RIGHTS: Information in your medical record that you have or may have a communicable or venereal disease is made confidential by law and cannot be disclosed without your permission except in limited circumstances including disclosure to persons who have had risk exposures, disclosure pursuant to an order of the court of the Department of Health, disclosure among health care providers or disclosure for statistical or epidemiological purposes. When such information is disclosed, it cannot contain information from which you could be identified unless disclosure of that identifying information is authorized by you, by an order of the court or the Department of Health, or by law.