RECORDS RELEASE COPY PASTE IN WORD PROCESSOR
PLEASE PRINT FILL OUT SEND TO YOUR PRIOR DOCTOR, HOSPITAL OR LAB
PAINPA, LLC, KENNETH ZAHL, M.D.
175 E BROWN ST, SUITE 201-B
EAST STROUDSBURG, PA 18301 www.PAINPA.com
PHONE 570-422-6666
FAX (570) 796-9246
Authorization to Release Records For________________________
DOB________________
SS No._________________________
1. I authorize the use or disclosure of the above named individual's health information as described below:
2. The following individuals or organizations is/are authorized to make the disclosure:
3. The type and amount of information to be used or disclosed is as follows: (include date where appropriate)
___ _Entire record ____Last two office visits and initial visit
____Laboratory results Please indicate the specific date range of (from date, to date) ____________or indicate most Recent________ or indicate "ALL":
___RADIOLOGY reports
Please indicate the specific date range of (from date, to date)_________
or indicate "ALL" :
Please indicate other type of information of which you are authorizing the release of.
____ OPERATIVE REPORTS
___ _ PROCEDRUE REPORTS
___ _ CONSULTATIONS
____ EMG/NERVE CONDUCTION TEST
____ PSYCHOLOGICAL RECORDS
4 I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drugs.
5.This information may be disclosed to and used by the following individual or organization:
Kenneth Zahl, MD/ PAINPA, LLC For the purpose of: Treatment
6. I understand I have the right to revoke this authorization at any time. I understand if I revoke this authorization, I must do so in writing and present my written revocation to the health information management department. I understand the revocations will not apply to information that has already been released in response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire in one year.
7. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand any disclosure of information carries wit it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact Dr Zahl.
By SIGNING BELOW I attest that the statements above are true and made of my free will.
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