Authorization for the Release of Protected Health Information
Hasib Mikael Sarij, M.D.
1111 Broad Hollow Rd. (Route 110) Unit 114 Farmingdale, NY 11735
Tel: (516) 336-8659 • 631-270-7733 / Fax: (516) 584-0055
Email address *
I give permission for Integrated Spine & Pain Care: *
Name of Person/Doctor/Hospital/Facility: *
Street Address
City
State
Zip Code
Phone Number *
Fax Number
Information to be released: *
Required
Purpose of disclosure: *
Required
Patient Name *
Date of Birth *
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Phone *
Disclose HIV/AIDS information *
I hereby authorize Integrated Spine and Pain Care and its employees the right to release any and all information contained in my medical records. Note: Release of “psychotherapy notes” as defined in 45 CFR 164.501 requires completion of separate authorization form. Information about diagnosis or treatment for alcohol/substance abuse and HIV/AIDS may be disclosed as follows:
Disclose alcohol/drug abuse information *
I hereby authorize Integrated Spine and Pain Care and its employees the right to release any and all information contained in my medical records. Note: Release of “psychotherapy notes” as defined in 45 CFR 164.501 requires completion of separate authorization form. Information about diagnosis or treatment for alcohol/substance abuse and HIV/AIDS may be disclosed as follows:
Patient Signature: (Print Full Legal Name) *
I understand that this authorization may be revoked by me (in writing) at any time except to the extent that action has been taken thereon. However, I understand that any actions already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. I acknowledge the potential for information disclosed pursuant to this authorization to be subject to redisclosure by the recipient and no longer be protected under HIPAA privacy rules. I understand that the covered entity to whom this authorization is directed may not condition treatment, payment, enrollment or eligibility benefits on whether or not I sign the authorization, unless a condition set forth at 45 CFR 164.508(b)(4) applies. Any facsimile, copy or photocopy of the authorization shall authorize you to release the records herein. This authorization shall be in force and effect until one year from the originally signed authorization.Access to medical information is the right of every patient, duplication and distribution is a service. As a professional courtesy, no cost is assessed for information released directly to your health care provider; all other release are subject to costs for copying and distribution.I understand that I am not required to sign this authorization and may refuse to sign it. I understand that I need not sign this form to ensure healthcare treatment.
Today's Date *
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Witness Signature: (Print Full Legal Name)
I understand that this authorization may be revoked by me (in writing) at any time except to the extent that action has been taken thereon. However, I understand that any actions already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. I acknowledge the potential for information disclosed pursuant to this authorization to be subject to redisclosure by the recipient and no longer be protected under HIPAA privacy rules. I understand that the covered entity to whom this authorization is directed may not condition treatment, payment, enrollment or eligibility benefits on whether or not I sign the authorization, unless a condition set forth at 45 CFR 164.508(b)(4) applies. Any facsimile, copy or photocopy of the authorization shall authorize you to release the records herein. This authorization shall be in force and effect until one year from the originally signed authorization.Access to medical information is the right of every patient, duplication and distribution is a service. As a professional courtesy, no cost is assessed for information released directly to your health care provider; all other release are subject to costs for copying and distribution.I understand that I am not required to sign this authorization and may refuse to sign it. I understand that I need not sign this form to ensure healthcare treatment.
Today's Date *
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