Authorization for Release of Medical Information

Authorization for Release of Medical Information

Patient Name ______Date of Birth ______

Patient Address ______Phone Number ______

I authorize The Nebraska Neurosurgery Group, LLC to release the following information to:

______Phone______

Address: ______City______State ______Zip ______

Dates of information to be disclosed: ______/______/______to ______/______/______

[ ] Procedure Notes [ ] Physician Clinic Notes

[ ] History and Physical [ ] Correspondence

[ ] Operative Notes [ ] Entire Record

[ ] Imaging Reports [ ] Financial Statement

Reason for Disclosure: ______

*  I understand that The Nebraska Neurosurgery Group, LLC will disclose only information completed or ordered by their clinical staff. Any outside information or independent review must be requested from that facility or responsible party. Please allow 3-5 business days for processing of all requests.

*  I understand I do not have to sign this authorization in order to obtain health care benefits (treatment, payment or enrollment).

*  I understand that a fee will be attached to obtain a copy of the requested records. The fee is $0.50 per page, $20 maximum. Full payment is required before records will be released. This fee will be waived if the records are sent directly to another provider from The Nebraska Neurosurgery Group, LLC.

*  I understand that once my information is disclosed, that information is subject to re-disclosure and may no longer be protected by the HIPAA Privacy Rule or other applicable law.

*  Unless otherwise revoked in writing, this authorization will expire one year from the date signed.

______

Signature of Patient or Legal Representative Date

______

If Signed by Personal Representative, Relationship to Patient