Use the following form to authorize ME to release your medical information TO someone else:

 

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION

 

Enter your identifying information:

Name of person releasing information:

 

DOB mmddyyyy

 

Address:

 

City, state, zip

 

Telephone:

 

 

I hereby authorize:

 

Mark Vakkur, MD, 160 Clairemont Ave., Suite 445, Atlanta, GA 30030

FAX #: (404) 500 4283

 

To disclose to:

Name of person to whom information is to be released:

 

Address:

 

City, state, zip

 

Telephone:

 

Fax #:

  

Is this a confidential, secure fax number?

  

 

The following information:

 

 

 

 

 

 

 

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This Authorization may be withdrawn at any time in writing except to the extent that the program or person which is to make this disclosure has acted in reliance on it.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 a $50 charge for copying records or preparing a summary narrative letter will generally apply.  

 

EXECUTED ON THIS DATE:

 

 

Please sign:

Patient or guardian:

 

 

Check [X] here if you are the legal guardian.

 

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

TO THE RECIPIENT OF CONFIDENTIAL INFORMA TION:

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 pemitted by 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.