B.D.S, D.D.S., MDSc
D.D.S., M.A -Ed
O.D., FAAO, FCOVD
Ph.D., O.D., FAAO
O.D., FAAO, FSLS
O.D., Ph.D., FAAO.
Foot and Ankle
D.O., AOBFP, AOBNMM
Osteopathic Manipulative Medic
PT, DPT, OCS, FAAOMPT
D.O., M.S., FACOFP
Pharm.D., BCPS, BC-ADM, FCCP
D.O., M.S., AOBNMM, AOBFP
This authorization will expire 1 year from 01/19/2020.
I understand I may withdraw my authorization at any time by submitting a written request to the HIPAA Privacy Officer. I understand any revocation is not effective to the extent action has already been taken in reliance on this authorization. I understand information used or disclosed pursuant to this authorization may be subject to re-disclosure and may no longer be protected by federal or state law. This authorization is not intended to affect a patient's ability to receive medical care.
Alcohol and Drug Abuse Treatment.
To the extent my medical record contains information regarding alcohol or drug treatment that is protected by federal law, I authorize the disclosure of such information or record.
HIV / AIDS Information
To the extent my medical record contains information regarding my HIV/AIDS status, treatment or testing, I authorize the disclosure of such information or record.
Behavioral Health Notes / Record
I authorize the disclosure of any behavioral health notes or information in my medical record.
With my digital signature below, I consent to the release of the above listed information / documents.
Community Partner site to email this completed form to firstname.lastname@example.org. Midwestern will
contact the patient to schedule an appointment within 48 business hours of receipt.