1075 N. Curtis Road, Suite 300
Boise, Idaho 83706
(208) 323-2600 ext. 3108
(208) 323-9172 fax
As required by the Health Insurance Portability and Accountability Act of 1996 Boise Orthopedic Clinic may not use or disclose your health information except as provided in our Notice of Privacy Practices without your authorization. Your signature on this form indicates that you are giving permission for the uses and disclosures of protected health information described herein. You may revoke this authorization at any time by signing and dating the revocation section on your copy of this form and returning to this office.
AUTHORIZATION SECTION
I, ______________________________________________ (print name legibly) hereby authorize the use and or disclosure of the following health information that pertains to me:
DOB: _______________ SSN: _____________________
_ Clinic Dictation _ Op Report _ Lab Reports
_ History & Physical _ Discharge/Transfer Summary _ CT Reports
_ Consultation _MRI Report _ Radiology Reports
_ X-Rays _ Other (specify)
_ All Records (BOC will not release medical records from other facilities unless specified)
_ All Records including outside records
I authorize Boise Orthopedic Clinic to make these disclosures of my health information To:
Facility:_________________________________________________________________________________
Address:_________________________________________________________________________________
City: _____________________________________________ State: ________ Zip: ___________________
Phone Number:_______________________________ Fax Number:_________________________________
I authorize Boise Orthopedic Clinic to receive these disclosures of my health information From:
Facility:_________________________________________________________________________________
Address:_________________________________________________________________________________
City: _____________________________________________ State: ________ Zip: ___________________
Phone Number:_______________________________ Fax Number:_________________________________
I understand that information disclosed pursuant to this authorization may be re-disclosed to additional parties and no longer protected.
I understand that I may revoke this authorization at any time by signing the revocation section of my copy of this form and returning it to Boise Orthopedic Clinic. I further understand that any such a revocation does not apply to the extent that persons authorized to use or disclose my health information have already acted in reliance on this authorization.
I understand that I have a right to inspect and to obtain a copy of any information disclosed pursuant to this authorization.
I understand that Boise Orthopedic Clinic will receive compensation for the uses and disclosures that I have authorized.
I understand that data to be released MAY INCLUDE material that is protected by Federal Law and that is applicable to substance abuse, mental health treatment information, HIV (AIDS) test results. My signature below authorizes release of all such information.
_____________________________________________ __________________________
I understand that this authorization will automatically expire one year from signature date.