Please Fax To Scanstat In Medical Records 9193135201 Phone

Please Fax To Scanstat In Medical Records 9193135201 Phone

DESCARGAR PDF


Please fax to Scanstat in Medical Records: 919-313-5201
Phone: 919-281-1839
Request for Protected Health Information / Patient Authorization for
Release of Records
Patient Name:
___________________________________________________________ S.S. #
________________________________
Date of Birth ______________________ Patient Phone Number(s):
_____________________________ MR/Chart Number _________
RELEASE INFORMATION TO: (recipient of disclosure)
Name: _______________________________________
Address: _____________________________________
Apt, Suite or PO #: _____________________________
City, State, and Zip: ____________________________
Phone: ______________________________________
Fax: ________________________________________
PERSON(S) / ORGANIZATION(S) AUTHORIZED TO MAKE DISCLOSURE:
Triangle Orthopaedics or
120 William Penn Plaza
Durham, NC 27704
*There is a charge for records for personal use/patient pick up. If
records are being requested to be sent to a lawyer, insurance or
workers compensation company, please have them contact us with a
written request; otherwise the patient will be charged.
TREATMENT DATES TO BE DISCLOSED:
___________________________________________________________
PURPOSE OF THE DISCLOSURE:  Insurance  Legal  Continuing Care 
Personal  Other (specify) ________________
SPECIFIC DESCRIPTION OF THE INFORMATION TO BE DISCLOSED:
Rehabilitation/Therapy Notes  Radiology  Behavioral Therapy 
Radiology Films  Other
SPECIFIC INFORMATION TO NOT BE DISCLOSED:
________________________________________
I understand that the purpose of this authorization is for the use
and/or disclosure of my protected health information (PHI) and that it
may contain information that is protected under state laws and federal
regulations. I understand that one the above information is disclosed
it may be subject to
re-disclosure and will no longer be protected by Privacy Protection
Rules. I understand that I have the right to revoke this authorization
at any time
and that my revocation must be submitted to the HIM Department at
Triangle Orthopaedics Associates. I understand that my revocation is
not
effective to the extent that the persons or organizations in which I
have authorized to use and/or disclose my protected health information
have
acted in reliance upon this authorization. I understand that I may
refuse to sign this authorization and my refusal to sign will not
affect my ability to receive treatment, payment enrollment, or
eligibility for benefits. I understand that I will be given a copy of
this authorization upon my signature.
I hereby authorize Triangle Orthopaedics Associates and or ScanSTAT
Technologies to disclose/release medical records and other information
obtained in the course of my diagnosis and/or treatment. I agree to
pay copy charges if applicable.
I hereby release Triangle Orthopaedics Associates and/or ScanSTAT
Technologies from any liability which may result from this disclosure
of confidential medical information or which may arise of the result
of the use of the information contained in the information released.
Unless withdrawn, this consent will expire 90 days from the date
signed.
This information may include Medical/Surgical, Psychiatric, Substance
Abuse and HIV/AIDS information.
I authorize that this information may be faxed when applicable.
____________________________________________________________
______________________________
PATIENT’S SIGNATURE DATE
____________________________________________________________
______________________________
PATIENT’S REPRESENTATIVE SIGNATURE AND AUTHORITY TO SIGN DATE
____________________________________________________________
______________________________
WITNESS DATE