HIPAA Authorization for Release of Medical Information
HIPAA AUTHORIZATION. ADVOCATE MDs HIPAA AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
I hereby authorize any physician, hospital, clinic, healthcare provider, insurance company, or other healthcare entity to release medical information regarding the patient named below to AdvocateMDs, including Dr. Steven Morris, MD and Dr. Mark Rubin, MD.
RECORDS TO BE RELEASED AND PURPOSE
The records to be released include medical records, test results, treatment plans, and verbal discussions with providers. The purpose of this authorization is to assist in medical advocacy, consultation, and care coordination.
I understand that this authorization is voluntary and that my health care or payment for my health care will not be affected if I do not sign this form. This authorization is valid for one (1) year from the date signed unless revoked in writing earlier.
Patient Name: __________________________________________________________________
Date of Birth: ___________________________________________________________________
Signature of Patient or Legal Representative: ________________________________________
Date: __________________________________________________________________________