Download Report

Authorization for Release Release of Information Medical Records Department 1111 Leffingwell NE Grand Rapids, MI 49525 Today’s Date _____________ Patient’s Name (First, Middle Initial, Last)__________________________________________ SS#_______________________ Date of Birth _______________________ Preferred Daytime Phone Number _______________________________ OK to Leave a Detailed Phone Message? □ Yes □ No E‐Mail Address _______________________________ Patient Mailing Address (Street, City, State, Zip) _________________________________________________________________ _________________________________________________________________________________________________ A) I hereby authorize records FROM:
B) To be released TO:
Name____________________________________________________________
Name: Orthopaedic Associates of Michigan
Address: 1111 Leffingwell NE
Address__________________________________________________________
City/State/Zip: Grand Rapids, Michigan 49525
City/State/Zip______________________________________________________
Fax#: 616-336-5042
Phone#: 616-459-7101
Phone#______________________FAX#________________________________
C) For the purpose of:
Date Range_____________________to___________________
□ Disability
□ Litigation
□ Physician Office Notes
□ Cardiology/EKG Reports
□ Work Comp
□ Immunizations
□ Lab/Path Reports
□ Insurance
□ Self/Personal Copy
□ Other ___________________ □ Operative/Procedure Reports □ Radiology/XRay/MRI Reports
□ Other _______________
□ Minimum Necessary
□ Transfer or Continuity of Care
I understand that this authorization is voluntary and that I may refuse to sign this authorization. I understand that if I refuse to sign, my refusal will not affect my ability to obtain treatment. I understand that I may revoke this authorization at any time by notifying Orthopaedic Associates of Michigan in writing. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. I understand that the information in my medical record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.
I have read the information provided on this release form and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization. This authorization will expire one year from the above date unless I specify an expiration date: __________________ Signature _____________________________________ *PLEASE READ Fee Information: Orthopaedic Associates of Michigan contracts with DataFile Technologies to copy and provide all medical records requested from our office. We reserve the right to charge the medical record state fee structure as set forth in the state statutes. Copy charges plus postage will be invoiced to you from DataFile Technologies, LLC with all of the necessary directions to receive your records. By signing this authorization, you are agreeing to pay DataFile Technologies for your records. In the case of continuity of care or personal copy to patient, we may transfer a minimal portion of your records as a courtesy. www.datafiletechnologies.com