Birmingham Gastro (Medical Records Release)

Patient Information

*Please provide your full legal name as it appears on your driver's license, state identification card, or government issued identification card.

Medical Records Release Form

AUTHORIZATION FOR USE/DISCLOSURE OF HEALTH INFORMATION

Birmingham Gastroenterology Associates; Phone: 205-271-8000; Fax: 205-879-7061; www.bgapc.com

* Required Information

Authorization for Use/Disclosure of Information: I voluntarily authorize and direct my health care provider, Birmingham Gastroenterology Associates.

Phone: 205-271-8000 Fax: 205-879-7061

My health information during the Term of this Authorization to the recipient that I have identified below.

*Purpose: I understand that the specific purpose of this Authorization is at the request of the patient.

*Information to be disclosed: This authorization permits the above provider to disclose the following medical records:

All of my health information that the provider has in his or her possession, including information relating to any medical history, physical condition and any treatment received by me, excluding HIV, STDs, drug/alcohol abuse or treatment and psychological/psychiatric, mental health, and psychotherapy notes.

I grant special authorization for all of my health information described above including HIV, STDs, drug/alcohol abuse or treatment and psychological/psychiatric, mental health information, and psychotherapy notes.

Only the following records or types of health information: (Dates of treatment, types of treatment or other)

*Term of Authorization: Remains in effect for 90 days or until the end of litigation (if not specified below):

From the date of this Authorization until the date of

Until the Provider fulfills this request.

Does not expire or until the following

Refusal to sign/right to revoke: I understand I may refuse to sign or may revoke (at any time) this Authorization for any reason and that such refusal or revocation will not affect the continuation or quality of my treatment by my health care provider.

Revocation: I understand that this Authorization remains in effect until the term of this Authorization expires or I provide a written notice of revocation to my health care provider's Privacy Officer at the address listed below. The revocation will be effective immediately upon receipt of my written notice, except that the revocation will not have any effect on any action taken by my health care provider in reliance on this Authorization before it received my written notice of revocation.

Date:

*Signature of Patient or Legal Representative:

Please sign in the box above

If individual is unable to sign this Authorization, please complete the information below:

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