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  psychiatric impairments, drug abuse, alcoholism, sickle cell anemia, HIV or Hepatitis infections for the  purpose of  provision of medical treatment and healthcare.

 

 

i understand the information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient, Top Flight Medical Group, or its physicians  or employees or agents any time prior to receipt of my revocation, and no longer be protected by the federal privacy regulations.  

 

Information to be disclosed to:

Lise LLC and Top Flight Medical Group. P. O. Box 292796 Nashville, Tennessee 37229 Phone 8777432646 and electronic mail address tfmedicalgroup@gmail.com and whose facsimile is 8774723945 or 8777432646

 

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 authorization. Lise LLC nor 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