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Professional Otolaryngology Associates HearMD A Division of Regional Otolaryngology Head and Neck Associates, L.L.C. James M. Sumerson, M.D., Stephen P. Gadomski, M.D., Samir Shah, M.D. Anthony Cultrara,M.D., Ashmit Gupta, M.D., M.P.H., Harry Cantrell, M.D., Roy D. Carlson, M.D. 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 or disclose information to the individual/organization identified below Copies 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 remain in effect from date of signature unless otherwise advised by patient or parent in relation to designated family members receiving medical information and addition/change of doctors. Otherwise, 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)
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