DEAN FOCHIOS, M.D., P.C., DANIEL BOWMAN, M.D., P.C.,
AND FOXCARE ORTHOPAEDICS
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

I, _____________________________________________________________, hereby authorize:
 
____________________________________________________________________________
Name of Physician/Practice/Insurance Carrier/Other
 
____________________________________________________________________________
Street Address
 
____________________________________________________________________________
City, State, Zip
 
______________________                                   ______________________
Telephone #                                                            Fax #
 
to disclose the following protected health information:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
(Specifically describe the information to be used or disclosed, including, but not limited to, meaningful descriptors such as date of service, type of service provided, level of detail to be released, origin of information, etc.)
 
The information is being disclosed for the following purposes:

z   For on-going treatment and care
z   Consultation or second opinion
Z   Other, please specify:_________________________________

The information is to be released to:
 
Orthopaedics
One FoxCare Drive, Suite 211
Oneonta, New York 13820
Phone: (607) 432-2239
Fax: (607) 432-2049

I understand that I have the right to refuse to sign this authorization.

My signature below indicates authorization to release the above-specified information to the party listed.
 
____________________________________
Signature of Patient or Personal Representative  		________________________________
Patient’s Date of Birth
____________________________________
Date 		________________________________
Patient’s Social Security Number
____________________________________
Name of Patient or Personal Representative		 ________________________________
Description of Representative’s Authority