Authorization for Disclosure

Authorization for Use or Disclosure of Information for Purposes Requested by Physician's Office

I, _____________________________________, hereby authorize Robert L Estes, M.D., to (check those that apply):

__ use the following protected health information, and/or

__ disclose the following protected health information to _________________________________________:

_____________________________________________________________________________________

[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.]

This protected health information is being used or disclosed for the following purposes:

_____________________________________________________________________________________

This authorization shall be in force and effect until [specify (1) date or (2) event that relates to the patient or the purpose of the use or disclosure] ________________________at which time this authorization to use or disclose this protected health information expires.

I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to Robert L Estes, M.D., at 2011 Murphy Avenue Suite 308, Nashville, TN 37203-2023 or rlestesm@bellsouth.net. I understand that a revocation is not effective to the extent that Dr. Estes has relied on the use or disclosure of the protected health information.

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.

Robert L Estes, M.D. will not condition my treatment, payment, enrollment in a health plan or eligibility for benefits (if applicable) on whether I provide authorization for the requested use or disclosure.

I understand that I have the right to:

Inspect or copy the protected health information to be used or disclosed as permitted under federal law (or state law to the extent the state law provides greater access rights.)
Refuse to sign this authorization.

[The use or disclosure requested under this authorization may result in direct or indirect remuneration to _________________________________________ from a third party.] [If applicable.]

_______________________________________
Signature of Patient or Personal Representative

_______________________________________
Date

_______________________________________
Name of Patient or Personal Representative

_______________________________________
Description of Personal Representative’s Authority