Release of Information From Elsewhere Form – OSNT

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:             _____Fax #  972-378-0656

_____Bradford A. Gamble, MD

Physician(s) sending records to Dr. Gamble:

_______________________________________________            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______________________

Other_________________________

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