AUTHORIZATION FOR RELEASE OF INFORMATION

 
 
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 info@topflightmedical.com or topflightmedical@meditouchehr.com 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
I certify that Iam the (choose one that applies): *
BY CHECKING  THE BOX, I HEREBY AUTHENTICATE  AND ACKNOWLEDGE AS TRUE, THAT  THIS  MEDICAL FORM IS  CORRECT, HAS BEEN REVEIWED BY ME, THE CLIENT,  AND  IS AN ACCEPTABLE  REPRESENTATION OF  MY CURRENT    APPLICABLE  HEALTH  STATUS *
Signature here authenticates all above for the client *
clear

If signature is NOT the patient's , complete the following please


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