Interventional Pain Management, Addiction Therapy
□ 13055 SW 42nd St, Suite 105, Miami, FL 33175
Tel: 786-780-1800, Fax: 786-780-2500
□ 10271 SW 72nd St, Suite 101, Miami, FL 33173
Tel: 305-595-6075, Fax: 305-595-6074
www.ApolloPainCare.com
Authorization for Release of Confidential Information
From APC
I, ______hereby authorize Apollo Pain Care, LLC to release medical, psychiatric, drug and/or alcohol abuse or HIV testing and AIDS information in my medical records to:
Name: ______
Address: ______
City: ______State: ______Zip: ______
Phone: ______Fax: ______
For the purpose of medical care.
I understand that the specific reports shall include ______
I understand that this consent is revocable upon written notice to Apollo Pain Care, except to the extent that action by Apollo Pain Care has been taken in reliance of this authorization and that this authorization shall remain in force for a reasonable time order to effect the purpose which it is given.
Alcohol abuse information, if present has been disclosed from records whose confidentiality is protected by Federal Law. Federal Regulation (42 CFR Part 2) prohibit making any further of it without the specific written consent of the undersigned, or as otherwise permitted by such regulations. HIV testing and/or AIDS related diagnosis is prohibited from further disclosure by State Regulations without consent from the patient.
______
Date Patient Name Patient Signature in full
______
Date of Birth Parent, Legal Guardian or Authorized Representative
______
Social Security Number Witness
***Patient may delete any of the categories above by marking through
Office Use Only
______
Specific records Released
______
Date of Release Released by
02/05/2016