I authorize Southeastern Spine Institute to use and disclose my protected health information for the purposes of treatment, payment, and healthcare operations.
Purpose of the Disclosure:
- Treatment: Your medical information may be used to provide medical treatment. This medical information may be used by and disclosed to physicians and other health care providers. This medical information is used to determine the most appropriate medical treatment for you.
- Payment: Your medical information may be used and disclosed so that the practice can bill and receive payment from you, your insurance company, and/or another third party for the treatment and services received.
- Healthcare Operations: Your medical information may be used and disclosed to evaluate the treatment and services performed by our staff and caring for you.
This authorization is valid for 12 months from the date of signature.
I understand that I have the right to terminate or revoke this authorization at any time. To do so, my request must be provided to your office in writing. I understand that revocation is not effective if my authorization was obtained as a condition of obtaining insurance coverage.
This signed PHI Form authorizes SSI to request and release Protected Health lnfonnation from other provider offices, and other medical facilities for the purposes of continuity of care. Please send copies of:
- Operative Reports (Spine Surgeries)
- Progress Notes
- MRI/X-ray Reports
- Bone Scans
- EMG’s
- Labs
- Any records relating to spine care treatment within the last year.