Please
complete the following form. Provide the name of your physician
on the first line. Put "all medical records" on line two -- or
qualify as
explained below the line. Put "continuing medical care" on line
three.
Mail the signed and completed form with the $75 fee to the address listed below.
Charts will be duplicated on a timely basis in the order in which they
are received.
___________________________________________________________
PATIENT
AUTHORIZATION FOR USE AND
DISCLOSURE OF PROTECTED HEALTH INFORMATION
By
signing this authorization, I authorize:
Paul
Chambliss, MD, PLLC
130 7th Avenue
#204
NYC, NY 10011
To
use and/or disclose certain protected health information (PHI) about me to:
____________________________________________________________________________
This
authorization permits Dr. Paul Chambliss to
use and/or disclose the following
individually identifiable health information about me (specifically describe the
information to be used or disclosed, specific date(s) of services, type of
services,
level of detail to be released, origin of information, and whether HIV testing
results/status are to be disclosed, etc.):
________________________________________________________________________
________________________________________________________________________
If
requested by the patient, purpose may be listed as “at the request of the
individual.”
The
purpose(s) is/are provided so that I can make an informed decision whether
to
allow release of the information.
This authorization will expire on: _____________________________
{Expiration
Date or Defined Event}
When
my information is used or disclosed pursuant to this authorization, it may
be
subject to re-disclosure by the recipient and may no longer be protected
by the
federal HIPAA Privacy Rule. I have the right to revoke this authorization
in
writing except to the extent that the practice has acted in reliance upon this
authorization. My written revocation must be submitted to Paul Chambliss,
MD,
PLLC.
________________________________________
___________________
Signature
of Patient or Legal Guardian
Date
__________________________________________
Printed Name