to disclose/release information regarding the person referenced above/below to the above named facility all of my medical records, including any specially protected records, such as those related to psychological or psychiatreic impairments, drug abuse, alcoholism, sickle cell anemia, HIV or Hepatitis infections for the purpose of provision of medical treatment and heatlthcare.
IF YOU DO NOT WANT CERTAIN PORTIONS OF YOUR MEDICAL RECORDS RELEASED, IDENTIFY PLEASE, THE INFORMATION THAT YOU DO NOT WANT RELEASED. OTHERWISE, YOUR RECORDS WILL BE RELEASED AS SPECIFIED ABOVE.
i understand the information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient, Top Flight Medical Group, or its physcicians or employees or agents any time prior to receipt of my revocation, and no longer be protected by the federal pricacy regulations.
Information to be disclosed to:
Top Flight Medical Group. P. O. Box 330760 Nashville, Tennessee 37203 Phone 6153403436 and electronic mail address email@example.com or firstname.lastname@example.org and whose facimile is 8774723945
Purpose of use: assistance in providing continuity of medical care
I understand that unless I revoke the authorization earlier, this authorization will automatically expire 12 months afte the date that this authorization is signed. Further, should i desire to revoke this authorization, I must send written notice to Top Flight Medical Group at the address shown above. I understand that revocation will not have any effect on my treatment by Top Flight Medical Group, its employees or agents prior to the time that any revocation is received.
I understand that I am not required to sign this authorzation. Top Flight Medical Group will not condition treatment , payment, enrollment or any eligibility for benefits on whether I provide this authorization.
Use of copies : A copy of this authorization may be utilized with the same effectiveness as an original