Annapolis Neurology Associates

Annapolis Neurology Associates

Authorization of Release of Information

Patient Name Date of Birth

Please release my healthcare Information from:

Annapolis Neurology Associates

Please send my healthcare information to:

Name and Address City, State, Zip Code Phone Number Fax or email address

Information to be released

Check appropriate box Specify information to be released

Purpose of Disclosure

Why are the records being released?

Patient Authorization

I understand that the information in my health record may include information related to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV) and Annapolis Neurology Associates is specifically authorized to release all health care information related to such diagnosis, testing and treatment.

My Rights

I understand that I do not have to sign this authorization in order to obtain health care benefits (treatment, payment or enrollment). I may revoke this authorization in writing. To view the process for revoking this authorization, please read the Privacy Notice to patients posted at the facility where your information is being released. I understand that once the health information I have authorized to be disclosed reaches the noted recipient, the person or organization may re-disclose it, at which time it may no longer be protected under Privacy Laws.

Signature and Date

Patient, Gaurdian or Authorized Representative Today's date

This authorization will expire 90 days from the date signed

Please note by typing the patient, guardian or authorized representative name, you are giving signed consent to release the patient's medical records to the healthcare facility or provider listed above.