Patient authorizes the physicians, medical attendants, and the hospital to furnish full and complete medical information to the specified attorney at law, or to any representative or investigator from his/her firm. The form also provides that all prior authorization is cancelled.
Medical Information Authorization Without In Cuyahoga
Category:
State:
Multi-State
County:
Cuyahoga
Control #:
US-00426
Format:
Word;
Rich Text
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Complete all fields on the authorization form when requesting the release of your records. If you do not know your Cleveland Clinic number, leave it blank.I, the undersigned, authorize (Disclosing Institution) and its employees to release Information from my medical records as described above. If Authorization is not complete, signed and dated, it may be returned and result in my information not being released until completed. HIPAA allows certain disclosures without the patient's written authorization, including disclosures to other providers or third party payers. (Client, Patient or Personal Representative).