ࡱ> @B?'` 8bjbjLULU 4:.?.?$8,,$(((((((($Ah4E((4((ygggd((gggF( J9d^0f,_ f_ _ |(>f,g$(((44d((($$$Dh$$$$h$$$  Authorization for the Release of Protected Health Information I authorize_____________________________________to release information from the record of: Name of Facility/Person ________________________________________________ ___________________ _____________________ to Patient Name Date of Birth Social Security # ____________________________________________________ ( )_________________ ( )___________________ Name of Facility/Person Phone # Fax # ___________________________________________________________________________________________________ Facility/Person Address for the purpose of (Provide a detailed description) ___________________________________________________________ Parts 1 and 2 must be completed to properly identify the records to be released. 1. Type of records to be released and approximate date(s) of service (circle all that apply): Inpatient Emergency Dept. Outpatient Physician Office/Clinic Dates: _________________________ I authorize the release of: (circle all that apply) Mental Health Information Drug & Alcohol Information contained in the records indicated above. 2. Specific information to be released (circle all that apply): Consults Medical History & Physical Radiology Reports Discharge Summary/Instructions Medication Records Other:_____________________________ Laboratory Reports/Tests Operative Report Mammography Report Pathology Report Emergency Dept. Report EKG Report HIV-related information contained in the parts of the records indicated above will be released through this Authorization unless otherwise indicated. % Do not release I understand that this authorization is effective for a period of 90 days from the date of the signature, unless otherwise specified Below. No time frame may exceed one year from the date of signature. I understand that I have the right to revoke this authorization at any time by sending a written request to the entity/person I authorized above to release the information. See side two of this form for additional patient rights and responsibilities. If applicable, specify other expiration date/event here:_______________________________________ ____________ __________________________________ _____________ ____________________________________ Date of Signature Signature of patient (18 yrs or older) Date of Signature Signature of Parent, Legal Guardian or Authorized Representative* (complete below) _____________ ______________________________________ Date of Signature Witness/Staff Member Signature *Authorized Representatives relationship and authority to act on behalf of patient: ______________________________________________ ORAL AUTHORIZATION (for persons physically unable to sign) NOT applicable to HIV related information or Drug & Alcohol treatment information I witness that the patient understood the nature of this release and freely gave their oral authorization. (Two witnesses are required) ______________ __________________________________ ____________ ______________________________________ Date Witness #1 Date Witness #2 Page 1 of 2 Additional Patient Rights and Responsibilities A disclosure statement, as required by law, will accompany all records released. Release of my records will be for the purpose stated on this form. Only those items checked off or listed will be released. Although applicable law may prohibit re-disclosure of these records, I understand that it is possible that the facility/person that receives the records may re-disclose the information, therefore Western Wake Surgical, PC and its staff/employees have no responsibility or liability as a result of any re-disclosure and such information would no longer be protected by the Privacy Rule (HIPPA), however, such information is always protected by the drug & alcohol regulations. My decision to revoke the authorization does not apply to any release of my records that may have taken place prior to the date of my revocation of the authorization. My decision to revoke the authorization my result in my insurance company not being able to pay for my medical care and I understand that I may be responsible for payment of the claim. Western Wake Surgical, PC cannot require me to sign the authorization in order to receive treatment. I am entitled to a copy of this completed authorization form. Staff Use Only Staff Member Signature: __________________________________________________ % ID obtained Type of ID: _________________________________ Date Records released: __________________ Page 2 of 2     WESTERN WAKE SURGICAL, P#?@ALXq_    $ P T  ! 9 : ɿĴ{rd[P{h[h[CJaJh[>*CJaJh[h[6>*CJaJh[5CJaJh[h[5CJaJh[CJaJh8 CJaJh!7h!7>*CJaJh!7CJaJh!75CJaJh!7h!7CJaJ haL55 h!75h!7haL55 h!7haL5h~;5>*CJ aJ haL55>*CJ aJ h~;h~;5>*CJ aJ h~;@A@ 8 3 Q : `gd!7$a$gd~;gd 8!8  "$DF'(g7KͿͩՠՏsg[g[I[:h%/h-_TB*CJaJph#h-_Th-_T5>*B*CJaJphh-_TB*CJaJphh[B*CJaJphh[5B*CJaJphh[5B*CJaJph h[h[5B*CJ aJ phh!75CJaJh[h[CJaJh!76>*CJaJh[h[6>*CJaJh[CJaJh[5CJaJh[h[5CJaJh[h!75CJaJhbj5CJaJ: hBD(j7^gd-_T`gd!7*$d%d&d'dNOPQ`gd[KOs&nq-./}شش}vk`XPXh8 CJaJhd&CJaJh8 5>*CJ aJ h-_T5>*CJ aJ h~;5>*h 8h 8B*CJaJphh 8B*CJaJphhd&5B*CJaJphh%/5B*CJaJphh%/B*CJaJphh8 B*CJaJphh'vB*CJaJphh-_TB*CJaJphh%/h-_TB*CJaJphh%/B*CJaJph-./010^0gdaD & Fgdd&gdd&$a$gd~;&d P ^gd-_T^gd-_T01W^23tSXos7  V \ !!!!!ооеоǾǾǵǾǾǾǾǾǾǾǾРРhUjhUUhd&hE5CJaJhE5CJaJh8 haD5CJaJh )g5CJaJh8 5CJaJhaD5CJaJhd&5CJaJhaDhaD5>*CJaJhd&5>*CJaJhaDhd&5>*CJaJ523ST678 0&d P ^0gdaD0^0gdaD & Fgdd&0^0gd8 gd8  !!!!!!!!!!!!!!48888888gd~;`gdd&gdd&0^0gdaD!!!!!!"888888hd&hE5CJaJh 8h~;h 8OJQJ^JUh 8OJQJ^JjhUUhU C 155 Parkway Office Ct., Ste 101 Eric D. Duberman Cary, N.C. 27518 (919)859-4747(phone) (919) 859-4757(fax) 21h:p 8/ =!"#$% @@@ NormalCJ_HaJmH sH tH DAD Default Paragraph FontRiR  Table Normal4 l4a (k(No List4@4 ~;Header  !4 4 ~;Footer  !-:@A@83Q:hc(  j 7   -./0123ST678 l*+.0000000000000000000000000000000000000000000000000000000000000 00 00 000 00 000 00 0000000000000000000000000@000@000@000@000@0@0@0@0@000.  K!8:  88HA*HA* DHA* HA*__dd.bbgk.;*urn:schemas-microsoft-com:office:smarttagsaddress:*urn:schemas-microsoft-com:office:smarttagsStreet9*urn:schemas-microsoft-com:office:smarttagsplace9*urn:schemas-microsoft-com:office:smarttagsState   +. +.3!n q W^22RSTXos67cf). +.7e@ Wlh^`OJQJo(hHhhh^h`OJQJ^Jo(hHoh88^8`OJQJo(hHh^`OJQJo(hHh  ^ `OJQJ^Jo(hHoh  ^ `OJQJo(hHhxx^x`OJQJo(hHhHH^H`OJQJ^Jo(hHoh^`OJQJo(hH7e@         x/ 8 %/4aL5!7 8aDE-_Tw4U ] )gchbjv'v~;d&0X[U/a@7/@ 88-@@@@$@@ @p@UnknownGz Times New Roman5Symbol3& z ArialO& k9?Lucida Sans Unicode?5 z Courier New;Wingdings"1hÆHCf:Cf qq )q )#4  2QKX ?~;20Authorization for the Release of Medical Records Debra Davis Debra Davis Oh+'0$ 8D d p | 4Authorization for the Release of Medical Records Debra DavisNormal Debra Davis13Microsoft Office Word@1@s@(Z@@4q՜.+,0, hp  Western Wake Surgical)  ' 1Authorization for the Release of Medical Records Title  !"#$%&'()*+,-.012345689:;<=>ARoot Entry F໠C1Tableo WordDocument4:SummaryInformation(/DocumentSummaryInformation87CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q