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Professional Otolaryngology |
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Professional Otolaryngology Associates A Division of Regional Otolaryngology Head and Neck Associates. L.L.C. HearMD James M. Sumerson, M.D. Emilio A. Roncace, M.D. Stephen P. Gadomski, M.D. Samir Shah, M.D. Anthony Cultrara, M.D. Ashmit Gupta, M.D., M.P.H. Suzanne E. Giacobbe, C.R.N.P. Authorization for Release of Medical Records Name of Patient: _____________________________________________________________________________ Address: ______________________________________________________________________________________ Telephone: _______________________________________________ Fax: _______________________________ Date of Birth: _________________________________________________________________________________ I authorize Professional Otolaryngology Associates, A Division Of Regional Otolaryngology Head and Neck Associates, LLC, Staffordshire Professional Center, 1307 White Horse Road, Building A/Suite 100, Voorhees, NJ 08043 to:□ Release or disclose information to the individual/organization identified below□ Obtain information from the individual/agency/organization identified belowCopies of all my records concerning (my child/self/guardian) which may include but may not be limited to: history and physicals, progress notes, consultations, operative notes, discharge summaries, diagnostic films, laboratory/pathology reports and other diagnostic reports. I understand that the information may also contain information from other healthcare providers as well as administrative data which is not strictly medical in nature. I am aware that some of this information may contain sensitive material with regard to alcohol and drug abuse, sexually transmitted disease, behavior or mental health, HIV/AIDS, hepatitis, or other communicable diseases. This information is being requested for the purpose of: ______________________________________________________________________________Person(s) Permitted to Receive/Send the Information: Name: _________________________________________________________________________________________Address:_______________________________________________________________________________________ Telephone #: ______________________________________ Fax #_____________________________________ Expiration Date of Event – This authorization shall expire 1 month from date of signature. Right to Revoke. You have the right to revoke this authorization and may do so by calling the office immediately. If we have already used or disclosed your protected health information before receiving your revocation, you understand that we cannot take back those uses or disclosures.Information May be Redisclosed. Information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and may no longer be protected by the HIPAA Privacy Rule. Date Signature ________________________________________________________________________________________________ Signature of Patient’s Personal Representative and description of his or her authority to act for the patient (Parent, Guardian, Other) Staffordshire Professional Center 130 Haddon Avenue The Health Center At Sicklerville Bldg. A, Suite 100 Haddonfield, NJ 08033 485 Williamstown-New Freedom Rd 1307 White Horse Road 856-429-5055 Sicklerville, NJ 08081 Voorhees, NJ 08043 Fax 856-429-1284 856-237-8020 856-346-0200 Fax 856-237-8024 Fax 856-309-8192 |