Medical Authorization - WC - todd sells
(Copy to Serve as Original)
I hereby authorize the above to disclose to THE FRIEDMAN LAW FIRM at 3401 Enterprise Pkwy., Suite 330, Cleveland, OH 44122 the following:
Medical records – Dates of service
Itemized bills – Dates of service
I understand I have the right to revoke this authorization at any time. I understand if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand the revocation will not apply to information that has already been released in response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire two years from the date signed below. If I fail to specify an expiration date, event, or condition, this authorization will expire in six months. I understand that the requested information may contain information concerning treatment for a sexually transmitted disease, alcohol, drug abuse, a psychiatric condition, or HIV test results, and AIDS diagnosis, or AIDS related condition.
I understand that some or all of the requested information provided to The Friedman Law Firm may be redisclosed to organizations which, and persons who, are not subject to federal and state protected health information privacy laws, and therefore that redisclosure by these organizations or people may not be protected by such laws.
I understand that treatment and payment may not be conditioned or revoked as a result of signing this authorization.
Name: todd sells
Date of Birth: 04/11/1963
Social Security Number: 292722805
|2017-05-04 13:23:18 EDT||Medical Authorization - WC Uploaded by Kristin Cool - email@example.com IP 126.96.36.199|
|2017-05-22 17:29:42 EDT||Document viewed by todd sells - firstname.lastname@example.org IP 188.8.131.52|
|2017-05-22 17:34:47 EDT||Document signed by todd sells - email@example.com IP 184.108.40.206|
|2017-05-22 17:34:47 EDT||The document has been signed by all parties and is now closed.|
|2017-05-22 23:04:38 EDT||Document viewed by todd sells - firstname.lastname@example.org IP 220.127.116.11|