MEDICAL RECORD AUTHORIZATION TO USE AND/OR DISCLOSE HEALTH INFORMATION

This authorization allows Interventional Pain & Spine Center (IPSC) to use and/or disclose protected health information (PHI), including medical records and billing statements.

Notice of Privacy Practices is available at www.ipscpgh.com

Patient Name

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Date of Birth:

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Address:

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Phone Number:

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Email Address:

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The patient authorizes the below listed medical facility to disclose all his or her medical records to Interventional Pain & Spine Center.

Name of the Facility:

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Address of the Facility:

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Facility phone number:

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Facility Fax number:

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Description of information to be disclosed/released:

Office visit notes/Consultations

Discharge summaries

Imaging

Lab work

Physical therapy notes

Confidential mental health visit notes

EEG/EMG/NCV Testing

Legal Records

Insurance records

Reason for release of medical information:

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Recipient of information:

Name:

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Email:

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Address:

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Expiration of authorization (date/event):

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If left blank, this authorization will automatically expire two years from the “Date” signed below.

You may refuse to sign this authorization, refusal will not affect your ability to receive medical treatment from IPSC except in cases where the care/consultation is solely to generate information for a third-party form.

Authorization may be revoked at any time except to the extent IPSC has relied on it. Revocation must be submitted in writing to:

Interventional Pain & Spine Center

100 Bradford Road, Suite 410
Wexford, PA 15090

Re-disclosure: Once information is disclosed to the recipient, it may be re-disclosed and no longer protected by HIPAA regulations.

Patients are responsible for ensuring that facility fax number is secure to comply with HIPAA Privacy regulations. IPSC is not responsible for unintentional receipt/interception of medical information sent to the fax number if provided above.

I have read and understand this authorization, and I voluntarily authorize Interventional Pain & Spine Center to use and/or disclose my health information as indicated above.

Printed Name:

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Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Date:

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Daytime Phone #:

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If applicable:

Name of Personal Representative/Parent (if under 18):

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Relationship to Patient:

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Return/Submission Instructions:
Mail: Interventional Pain & Spine Center, 100 Bradford Road, Suite 410, Wexford, PA 15090
Fax (secure): (724)965-8953
Questions: (724) 965-8946