Information Requested: I consent and authorize SurgOne, P.C. to disclose all Protected Health Information in any form (including oral, written or electronic) to:
(list individual, facility, address, city, state, zip) (the “Requestor”). Additionally, I authorize SurgOne, P.C. to disclose the PHI via mail or facsimile. I expressly request that SurgOne, P.C. disclose full and complete PHI from the time period of:
including, but not limited to, the following:
In addition to the authorization provisions above, I authorize the release and re-disclosure of all information, data, notes, records, reports, and all other documents to the Requestor, its consultants, experts, agents and/or other counsel relating to:
This form does not authorize re-disclosure of medical information beyond the limits of this consent. Where alcohol/drug abuse information has been disclosed through records that are protected by federal law, or mental health records protected by state law, further disclosure is prohibited without specific written consent of the individual or as otherwise permitted by such law and/or regulations. A general authorization is not sufficient for these purposes.