ATLZ05 Authorization and Medical Release Form

Authorization / Medical Release Form

This form is used by Atlantic Prosthetics & Orthotics to request your medical records from other providers and facilities so that we may better treat you. Please note that in some cases your insurance requires us to obtain clinic notes from the providers that treat you for the same conditios that we are treating your for.
Patient Name

First NameMiddle NameLast Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
By signing below I authorize Atlantic Prosthetics & Orthotics to obtain medical records from my other providers and/or facilities in order to better treat me.
For Office Use - Medical Record Number
Date of Service Requested

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

CHECK the specific documents that you are requesting

Rows	Requested Documents	Notes or Comments
Clinic Notes
Radiology Reports
Physical Therapy Notes
Operative/Procedure Notes
History & Physical
Film/CD Imaging
Provider Orders
Consultations
All Medical Records

CHECK the purpose of the request

Rows	Purpose of Request	Details or Other information?
Attorney/Legal
Personal Use
Continued Patient Care
Social Services/Disability
Insurance
Other

CHECK how you would like the receive your request

Rows	Send requested materials via:	Details or information needed to send requested materials:
Mail to address above
Fax to facility
Fax to patient listed above
Verbal release
Pick up in person
Other

Unless otherwise revoked, this authorization will expire on the following date, event or condition:
I UNDERSTAND THAT:

A. I may revoke authorization at any time:

The revocation will not apply to information that has already been released in response to this authorization
I must revoke this authorization in writing. The procedure for revoking this authorization is to present a written revocation to the facility.
B. I may refuse to sign this authorization:

My treatment, payment, enrollment in a health plan, or eligibility for benefits can not be conditioned upon my authorization of this disclosure.
I have been informed and understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient of such information. It is possible that once disclosed, the privacy of the information may no longer be protected under federal medical privacy laws.
If I fail to specify an expiration date, event or condition, this authorization will expire automatically in ninety (90) days from the date of signature.

I have read and understand the information in this authorization form.
Date of Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Digital Signature Authorization:
Signature
Name

First NameLast Name
Digital Signature Authorization for Authorized Representative:
OR - Signature of Authorized Representative
Name of Authorized Representative

First NameLast Name
Please explain Representative's authority to act on behalf of the patient
FOR OFFICE USE ONLY

Processed Date:____________________________________________

Processed By:______________________________________________

Signature:_________________________________________________

Additional Notes:
Should be Empty: