AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION. I hereby authorize Motivate to release information required in the processing of application for financial coverage for services rendered. This authorization provides that my physician or my physician’s staff may release objective clinical information related to my diagnoses and treatment, which may be requested by my insurance company or its designated agent. This authorization also includes any medical records containing information related to HIV (Aids) testing and/or psychiatric care rendered to me if such records are released to an insurance company writing Life, Accident or Health Insurance or a Non Profit Health Care Service Plan Corporation to evaluate my claims or its liability under such policies or contracts or coordination of benefits pursuant to such policy or contract provisions. The information obtained will be treated as privileged and confidential and will not be released to any person without my expressed or written consent. Correspondence and test results will only be released to physicians involved in my care.
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION. I authorize the release of all or any part of the contents of my medical records to the following: (1) to persons, corporations or other entities responsible for payment of all or part of my hospital or physician charges including, but not limited to, hospital or medical services companies, insurance companies, workers’ compensation carriers, employers, any and all government agencies, welfare agencies; (2) to persons, corporations or other entities providing health care services and supplies to me in cooperation with Xxxxxxx, its staff and employees during my hospitalization, whose services are deemed necessary and requested by my treating physician; (3) to persons, corporations or other entities providing accounting, billing, credit, payment, or collections services to, for, or in cooperation with Xxxxxxx; and (4) to any health care provider(s) that will provide continuation of my health care immediately following my discharge from Xxxxxxx. I further authorize disclosure of my medical record and any written communications, reports, or other data concerning my treatment while a patient at Xxxxxxx to my insurance carrier.
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION. I hereby authorize any physician or other healthcare professional, hospital or healthcare-related facility, pharmacy, medical service provider, employer, benefit plan administrator, and any Federal, State or Local Government Agency, with a complete copy of any and all medical information for use and disclosure as described in this authorization. Further to release any medical and other information in your possession or control to International Claims Services (ICS) and/or their attorneys, either directly or through a representative agent acting on their behalf, any and all medical information they may request, including but not limited to, medical records, reports, charts, graphs, x-ray notes, films, and laboratory reports. I also hereby authorize the release of all medical information regarding diagnosis, care and treatment for alcohol abuse, drug abuse or mental health. In addition, I authorize the release of any and all billing records and statements in your possession or control. I also authorize ICS, its representatives or their agents to release information that is obtained pursuant to this authorization to providers of healthcare, insurers, reinsurers, or claims administrators, and any government agency as it deems appropriate solely for the purpose of evaluating and administering any claim for benefits. I further understand that information may be released as follows: To other persons or organizations performing business or legal services in connection with any claim; As may be otherwise lawfully required; To any person or legally authorized representative as I have so indicated; As I may further authorize; or as necessary to prevent or detect the perpetration of fraud. This “Authorization For Release of Medical Information” is subject to revocation at any time except to the extent that action has been taken in reliance hereon and, if not earlier revoked in writing, it shall remain valid for two (2) years from date of signature. I agree that a photocopy, e-mailed copy or facsimile (FAX) copy of the authorization shall be accepted and as valid as the original. I know that I may request to receive a copy of this Authorization.
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION. I hereby authorize any physician who has information about my medical condition or my past medical history to furnish such information to Well-Spring, A Life Plan Community for the purposes of evaluating my health any physical condition for acceptance into Well-Spring.
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION. TO: (insert name and address of your Doctor or any Medical Practitioner who you are requesting to release your information): SIN#: Address: Telephone #:
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION. I authorize the examining health care practitioner to disclose to the Department of Social Services any information provided, any diagnoses made, conditions revealed, functional limitations and any prognoses identified, as a result of the examination given. I understand that this information will be treated as confidential. Client Signature x Date: Autorizo al médico examinador a revelar al Departamento de Servicios Sociales todo dato relativo a diagnósticos, aflicciones médicas, limitaciones funcionales y todo prognosis detectado como resultado del examen realizado. Entiendo que estos datos son de carácter confidencial. Firma del Cliente x Fecha:
