to release any and all medical records and medical information you have for me in your posession regarding my medical condition, records of consultations I have had, records of medications prescribed for me, hospital records, imaging, or labwork.
Please Fax these records to: Dr. Cortez, Sprague and Associates
***************************** Confidential Information **************************
I understand that the information to be released may sontain information relating to sexually transmitted diseases (STD), acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), alcohol or drug abuse, and Mental Health Information. I authorize the disclosure of this information.
This authorization is intended to be an unlimited, full, and complete Authorization for the release of any and all protected medical information as defined under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Medical Records Access Act, as amended, under the rules and regulations thereof, and covers all protected information from primary and secondary providers, health plans, health care clearinghouses, emergency services, financial and administrative transactions, and business associates. A covered entity may not condition treatment, payment, enrollment, or eligibility for benifits on whether I sign this authorization when the prohibition on conditioning of authorizations in 45 CFR 164.508(b)(4) applies. It is understood that the person to whom this Authorization is given has my permission to use and disseminate this information in his or her sole discretion.
1) Expiration: This expiration expires 18 months after I (the patient) sign this release.
2) Right to Revoke: I have the right to revoke this authorization by signing and dating a written statement revoking this authorization, and it shall become effective on delivery to you. If this Authorization is revoked, any person or entity acting in good faith in reliance upon it and lacking actual knowledge of its revocation shall be held harmless.
3) Re-Disclosure: Information used or disclosed persuant to this Authorization may be subject to re-disclosure by the recipient and is no longer protected by this rule.
4) Administrative Provisions: I revoke any prior authorization I have made to disclose health information that are inconsistent with this authorization. This document shall be governed by Arizona law and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). However, I indend to be honored in any jurisdiction where it is presented and for other jurisdictions to refer to Arizona Law and HIPAA to interpret and determine the validity and enforcability of this document. Phosocopies or facsimile reproductions of this signed Authorization shall be treated as original counterparts. I am providing this Authorization voluntarily and have not been required to give it to obtain treatment. I am at least 18 years of age and of sound mind.
Dr. Cortez, Sprague and Associates
FAX: (888) 537-5094 Phone: 845-478-0111
101 AVENUE OF THE AMERICAS, New York, New York 10013