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Medical Records Release Authorisation Form

AUTHORIZATION FOR USE/DISCLOSURE OF HEALTH INFORMATION TO MARTIN G GREGORIO MD AND ASSOCIATES

AUTHORIZATION FOR USE/DISCLOSURE OF HEALTH INFORMATION TO MARTIN G GREGORIO MD AND ASSOCIATES

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Authorization for Use/Disclosure of Information: I voluntarily consent to authorize my health care provider to disclose my health information during the term of this Authorization to the recipient(s) that I have identified below.
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Name: Martin G Gregorio MD and Associates
Address: 1500 Village Run Road, Suite 308 Wexford PA 15090
Fax: 724-934-3388
Phone: 724-934-1900

Purpose: I authorize the release of my health information for the following specific purpose:

Information to be disclosed: I authorize the release of the following health information: (check the applicable boxes below)

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Term: I understand that this Authorization will remain in effect:

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Redisclosure: I understand that my health care provider cannot guarantee that the recipient will not redisclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information.
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If Individual is unable to sign this Authorization, please complete the information below:

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