Release of Health Information

Please complete this form if you would like to request records to be sent to another Physician or if you would like to authorize another Physician to release records to Fagan Sports Medicine.

Patient Name *
Patient Name
Date of Birth *
Date of Birth
Authorization
I Authorize the above group and its employees to use and /or disclose the following protected health information to:
Address records are being sent to: *
Address records are being sent to:
Phone Number: *
Phone Number:
Fax Number
Fax Number
The type and amount of information to be used or disclosed is as follows: *
I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocations to the Privacy Officer. 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.
Name of patient or patient's representative *
Name of patient or patient's representative
Date *
Date