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Medical Records Release

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PATIENT INFORMATION

Full Name

RECORDS REQUESTED

Please Send

Purpose of Disclosure: Bariatric surgery and/or medical weight management evaluation and treatment.

PATIENT AUTHORIZATION & ACKNOWLEDGMENT

I authorize any physician, medical practice, hospital, healthcare facility, laboratory, imaging center, or other healthcare provider receiving this authorization to release my health information and medical records to:

BodyByBariatrics
Fax: 407-707-8658
Email: Support@BodyByBariatrics.com

I authorize any physician, medical practice, hospital, healthcare facility, laboratory, imaging center, or other healthcare provider receiving this authorization to release my health information and medical records to: BodyByBariatrics Fax: 407-707-8658 Email: Support@BodyByBariatrics.com
Required

I understand that:

  • I may revoke this authorization at any time by providing written notice to BodyByBariatrics, except to the extent that action has already been taken in reliance on this authorization.
  • My treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization, except as permitted by law.
  • Information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations.
  • A copy or electronic copy of this signed authorization is as valid as the original.
  • This authorization will expire one year from the date of my signature, unless I revoke it earlier in writing.
I understand that: I may revoke this authorization at any time by providing written notice to BodyByBariatrics, except to the extent that action has already been taken in reliance on this authorization. My treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization, except as permitted by law. Information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations. A copy or electronic copy of this signed authorization is as valid as the original. This authorization will expire one year from the date of my signature, unless I revoke it earlier in writing.
Required
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