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

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________
 (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 leased, origin of information, etc.)

The information is being disclosed for the following purposes:

   For on-going treatment and care.
   For a Worker's Compensation or Disability claim.
   For processing and payment of an insurance claim.
   For research purposes.
   For a Life Insurance Policy.
   Other, please specify ________________________________________________________

The information is to be released to:

____________________________________________________________________________
Name of Physician/Practice/Insurance Carrier/Other
 
____________________________________________________________________________
Street Address
 
____________________________________________________________________________
City, State, Zip
 
______________________                                   ______________________
Telephone #                                                            Fax #
 
 
 

I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.  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