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Get Laser Spine Institute Patient Authorization for Release of Medical Information 2014

Patient Authorization for Release of Medical Information This form allows LSI LLC to send records on your behalf Laser Spine Institute LLC Medical Records Department 3031 N. Rocky Point Drive E. Tampa FL 33607 Phone 813-289-9613 Fax 813-597-2616 Patient Name Date of Birth Address City Phone Last 4 digit SS State Zip Email I hereby authorize Laser Spine Institute LLC its affiliates medical staff employees and their representatives to release my protected health information in the manner listed below and to the following Send by choose ONE Mail Fax Secure Email Send to Name Zip Email Please send All Records Notes Labs Reports CD or Specific Item Only please list Depending on your request it can take 2-3 weeks to receive records though most requests are fulfilled sooner This authorization will not expire except when revoked by the patient legal guardian power of attorney or healthcare surrogate. I understand that I have the 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 request 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 once the information is disclosed it may be re-disclosed by the recipient and the information may not be protected under federal privacy laws or regulations. I understand LSI will not condition treatment or payment based on utilized with the same effectiveness as an original* I am entitled to receive a copy of this authorization* Signature of Patient/Guardian/Power of Attorney/Healthcare Surrogate Date Printed Name Relationship to Patient if Applicable Rev* 03. I understand that I have the 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 request 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 once the information is disclosed it may be re-disclosed by the recipient and the information may not be protected under federal privacy laws or regulations. I understand that the revocation will not apply to information that has already been released in response to this authorization* I understand that once the information is disclosed it may be re-disclosed by the recipient and the information may not be protected under federal privacy laws or regulations. I understand LSI will not condition treatment or payment based on utilized with the same effectiveness as an original* I am entitled to receive a copy of this authorization* Signature of Patient/Guardian/Power of Attorney/Healthcare Surrogate Date Printed Name Relationship to Patient if Applicable Rev* 03. I understand that I have the 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 request 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 once the information is disclosed it may be re-disclosed by the recipient and the information may not be protected under federal privacy laws or regulations. I understand LSI will not condition treatment or payment based on utilized with the same effectiveness as an original* I am entitled to receive a copy of this authorization* Signature of Patient/Guardian/Power of Attorney/Healthcare Surrogate Date Printed Name Relationship to Patient if Applicable Rev* 03. .

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