Piedmont HealthCare ¨ Robert I. Saltzman, MD, FACS ¨ Orthopaedic Surgery

770 Hartness Road ¨ Statesville, NC 28677 ¨ Fax 704-873-1853 ¨ Phone 704-878-9800

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

______

Print Patient Name Date of Birth

______

Street Address / P.O. Box Phone (home)

______

City / State / Zip Code Phone (work)

I hereby authorize information from my medical record to be released to/from the following facility / physician / person:

SEND MEDICAL RECORDS TO: MEDICAL RECORDS FROM:

______

Name (facility / physician / person) Name (facility / physician / person)

______

Address Address

______

City, State, Zip Code City, State, Zip Code

______

Phone Number Phone Number

The specific information to be released includes:

Immunization Records Office Visit Notes X-Ray Reports

Last Physical Lab Reports / Pathology Reports Other ______

Covering the dates of treatment from ______to ______.

I understand that the information released may include information related to AIDS (Acquire Immunodeficiency Syndrome) or HIV (Human Immunodeficiency Virus) Infection, psychiatric care and/or psychological assessment, or treatment for alcohol and/or drug abuse, unless otherwise specified here: ð Do not release

The purpose for the release of this information is:

Patient Request ð Transferring Physicians ð Moving Insurance Referral from PHC Physician ð Other ______

ð Legal Purpose______

I have been provided with a copy of Piedmont HealthCare’s Notice of Privacy Practices. I understand that I may revoke this authorization at any time in writing to the PHC Privacy Officer (see Notice of Privacy Practices) or to the office where this authorization was submitted except to the extent that the information has already been released. This authorization will expire 90 days after the date of signature. I understand that there is the potential that the information released by my authorization may be subject to re-disclosure by the recipient of the information. Piedmont HealthCare may not condition treatment or payment on my signature on this Authorization except in the case of research-related treatment or other such reasons as may be defined in the HIPAA Privacy Rule.

______

Signature of Patient or Personal Representative Date

If personal representative, please check legal authority to act on patients behalf:

ð Parent of Minor ð Guardian ð Power of Attorney ð Executor of Estate ð Other______

NOTE: THERE MAY BE A CHARGE FOR COPYING YOUR RECORDS--APPLIED IN ACCORDANCE WITH NORTH CAROLINA LAW.