Urology Specialists, S.C. - Release from Urology Specialists

AUTHORIZATION FOR
RELEASE OF CONFIDENTIAL HEALTH INFORMATION

Urology Specialists, S.C.
1725 W. Harrison Street, Suite 352
Chicago, Illinois 60612
Phone: (312) 563-5000
Fax: (312) 563-5007

THIS WILL AUTHORIZE YOU TO RELEASE INFORMATION TO:	____________________________________________________ (name)
	____________________________________________________ (address)
	____________________________________________________ (city) (state) (zip)
	____________________________________________________ (area code & phone)
FROM THE RECORDS OF:	____________________________________________________ (last name) (first name) (mi)
	SSN: _________________________________________
	DOB: _________________________________________

WHILE UNDER THE CARE OF:	____________________________________________________ (doctor's name)
APPLICABLE DATES:	______________________________________________

THE PURPOSE OF THIS AUTHORIZATION IS:	______ Transfer of care ______ To assist with diagnosis or treatment ______ Process insurance/disability claims ______ Process insurance application ______ Legal (please specify) ______________________ ______ Other (please specify) ______________________

I understand that I have the right to inspect and copy the information I have authorized to be disclosed by this authorization. In the event I refuse to authorize the release of the above-described information, I understand that it will not be disclosed, except as provided by law. I understand that the practice may not condition treatment on whether I sign this authorization, except when the provision of health care is solely for the purpose of creating protected health information for disclosure to a third party. 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 law. I understand that this authorization is valid until it expires one year from the date written below, unless revoked before that. I understand that I may revoke this authorization at any time by giving written notice to the physician of my desire to do so. I also understand that I will not be able to revoke this authorization in cases where the physician has already relied on it to use or disclose my health information.

_____________	______________________________	_______________________
Date	Patient, please PRINT your name above	Patient Signature Above

_____________	______________________________	_______________________
Date	Witness, please PRINT your name above	Witness Signature Above