AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION

Name of person releasing information:

 

DOB mm/dd/yyyy

 

Address:

  

Telephone:

      

I hereby authorize:

 Mark Vakkur, MD
www.vakkur.com
mvakkur@gmail.com
404 964 9883
fax: 877-512-4854  (efax, confidential, secure)
160 Clairemont Ave. Ste 445
Decatur, GA 30030

To disclose to:

Name of person to whom information is to be released:

  

Address:

  

 

Phone number:

  
 

The following information (check all that apply):
 

 [] minimal information necessary for billing or scheduling purposes (may include diagnosis, CPT code of service rendered, dates and times of service, and amounts charged or collected);

 

 [] minimal clinical information necessary to coordinate care with another provider (e.g., diagnosis, medication dose and response;

 

 [] any relevant clinical information.

 

 [] other [please note any restrictions on what you would like me to disclose; generally I disclose only the absolute minimum necessary to satisfy the purpose of the communication]:

 

 

 

 

For the following purpose:

  
 

A copy of this release is as valid as an original.
This Authorization may be withdrawn at any time in writing except to the extent that the program or person which is to make this disclosure has acted in reliance on it. Upon revocation of authorization, further release of information shall cease immediately. This release of information expires in 30 days following completion or termination of treatment, except for information to be released or exchanged for purposes of a claim for benefits. If for a claim for benefits, this release of information expires upon termination of coverage under the insurance policy or benefit plan or the final determination of the claim, if later.
I understand that I may be charged a reasonable fee for communication to third parties by my provider and that this fee may not be covered by insurance.

 

  

EXECUTED ON THIS DATE:

  

Please sign:

 _________________________________________
A copy of this executed release serves the same purpose as an original.

 

TO THE RECIPIENT OF CONFIDENTIAL INFORMATION:

If the information disclosed to you relates to substance abuse treatment, these records' confidentiality is protected by federal law. Federal regulations (42 CFR Part 2) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise pemittedby such regulations. A general authorization for the release of medical or other information is not sufficient to release substance abuse records. The Federal Rules restrict any use of the information to criminally investigate or prosecute any substance abuse patient. State laws may also protect the confidentiality of patient's records.