OSNT: Otolaryngology Specialists of North Texas
Release of Information Authorization Form
Release of information FROM another doctor or healthcare facility to Otolaryngology Specialists
PATIENT NAME:________________________________________________________ DOB: _____________________________________
I hereby authorize the named health care provider below to release the information or records specified TO Otolaryngology Specialists of North Texas upon request in person or by mail to the address specified.
Physician receiving records: _____Gregory N. Rohn, MD _____Fax # 972-378-0656
_____Bradford A. Gamble, MD
Physician(s) sending records to Drs. Gamble or Rohn:
_______________________________________________ Phone #_________________________
_______________________________________________ Fax # ___________________________
Specific information being requested: (Please indicate approx. date of information)
X-Rays________________________ Sleep Study______________________
CT’s __________________________ OP Report_______________________
MRI’s_________________________ Path Report______________________
Office Notes___________________ Audiograms______________________
This information will be used for the purpose of providing medical care.
This authorization shall be in force and effective until ___/___/______ (MM/DD/YYYY) at which time this authorization to use or disclose this protected health information expires.
I further understand that:
- I am not required to sign this authorization and that my healthcare or payment for care will not be affected by my refusal.
- Consent will expire 180 days after the date of my signature.
- There is the potential for information disclosed pursuant to this authorization to be subject to redisclosure by the recipient and no longer protected by federal privacy regulations.
- I am entitled to receive a copy of this authorization.
- A copy of this authorization may be utilized with the same effectiveness as the original.
- I have the right to revoke this authorization, in writing, at any time by sending such written notice to Otolaryngology Specialists of North Texas, except to the extent that OSNT has already used or disclosed information in reliance on this authorization.
____________________________________ ______ ______________________________________
Signature of patient or legal representative Date
Printed name of patient’s representative Relationship to the patient