Authorization For Use Or Disclosure Of Medical Record Information

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Address

Release Information To

I hereby authorize TopCare Medical, PA to release my medical record information to:
Address
Purpose of Request

Information to be Released

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the individual or organization releasing information. I understand that the revocation will not apply to information already released in response to this authorization. I understand that 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 expires upon one (1) year.

I also 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 ensure treatment.

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Authorization to Release Protected Information

Please put a checkmark in ALL the check boxes below, indicating how protected information should be handled even if the categories are applicable or not to the patient’s medical records. If form is incomplete, or if protected information is not released, we may be unable to fulfill this request.

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