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... pain free.
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Our Team
- Dr. Curtis D. Burton
- Dr. Richard L. Baumann
- Dr. Rahul Basho
Areas of Practice
- Sprains
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- - Request for Release of Records
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- Guide to Elbows
- Guide to Knees
- Guide to Shoulders
- Diet Tips
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- Osteoarthritis
Contact Us
Home
About Us
Our Team
Dr. Curtis D. Burton
Dr. Richard L. Baumann
Dr. Rahul Basho
Areas of Practice
Sprains
Neck & Back
Carpal Tunnel
Fractures
Shoulder
Knee
Elbow
Hip
Patient Toolbox
Pay Your Bill
Patient Portal
What to Bring to the Hospital
Insurance Information
Helpful Links
Patient Forms
Request for Release of Records
News & Press
Videos/Testimonials
Success Stories
Patient Education
Easing the Pain
Understanding Arthritis
Vacationing with Arthritis
Guide to Hips
Guide to Elbows
Guide to Knees
Guide to Shoulders
Diet Tips
Helpful Exercises
Osteoarthritis
Contact Us
Request for Release of Records
AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION
-
Step
1
of 7
Name
*
First
Last
Date of Birth
*
Address
*
SSN
*
Next
Authorization
*
I authorize the use or disclosure of the above named individual’s health information as described below.
The following individual /organization is authorized to make the disclosure (organization to release the records):
The type of information to be used or disclosed is as follows (request only the information you want released)
All medical records from your facility.
Consult Notes
Operative reports
Only records from (DATE to DATE)
Testing and/or lab results (describe the dates or type of tests you would like disclosed):
X-rays and/or other imaging films (please describe the dates or types of x-ray or images you would like disclosed):
Other (please describe):
Other types of information to be used or disclosed (Other)
Medical Information only
Financial Information only
Medical and Financial Information
Verbal only
Written only
Verbal and Written
Next
The information identified above may be used by or disclosed to the following individual/organization:
(To whom are the records being released. — If family, list name and relationship)
Name
Phone
Address
Fax
To be
Mailed
Faxed
Picked Up
Records needed by date
Date to be picked up
Processed by date
Next
The information will be used for the following purpose (check as many as applicable):
My personal records
Disability Claim
Social Service Agency
Second opinion (as recommended by my physician)
Referred to specialist
Attorney
Insurance Company
Relocation of self of family
Second opinion (as preferred by patient)
Transfer of care
Other
Next
This authorization will expire (insert date or event):
Next
Agreements
*
I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Medical Records department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.
If I fail to specify an expiration date/event, this authorization will expire 1 year from the date it was signed.
I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome(AIDS), or human immunodeficiency virus(HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and Abuse. 8-18-42 308- 625.3
Next
I understand authorizing the use or disclosure of the information identified above is voluntary. I need not sign this form to ensure healthcare treatment.
Name (must be 18 or older)
*
First
Last
Date
*
Submit