Laser Spine Institute PDF Details

If you're like most people, you probably cringe at the thought of having to complete a form. Filling out paperwork can be time-consuming and often redundant. But when it comes to your health, completing forms is essential. That's why Laser Spine Institute has made our patient forms available online. You can complete them in the comfort of your own home, and then print them out and bring them with you to your appointment. Completing our forms will help us get started on your treatment as quickly as possible.

You will discover information regarding the type of form you intend to submit in the table. It will tell you the span of time you will require to complete laser spine institute, what fields you will have to fill in and some further specific details.

QuestionAnswer
Form NameLaser Spine Institute
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmedical re3cord relear form, medical records release forms, laser spine insttute medical records department, release of medical records form

Form Preview Example

Patient Authorization for Release of Medical Information

This form allows LSI, LLC to send records on your behalf

Laser Spine Institute, LLC

Medical Records Department

3031 N. Rocky Point Drive, E., Tampa, FL 33607

Phone: 813-289-9613 Fax: 813-597-2616

Patient Name_

 

Date of Birth

 

 

Last 4 digit SS#_ _______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

City

 

State

 

Zip ______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone #

 

 

 

Email

 

 

 

 

 

 

 

 

I hereby authorize Laser Spine Institute, LLC, its affiliates, medical staff, employees, and their representatives to release my protected health information in the manner listed below, and to the following:

Send by: (choose ONE): Mail

Fax Secure Email

 

 

 

 

 

 

Send to:

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

________

Address

 

 

 

 

City

 

 

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone#

 

 

Fax#_

 

 

 

Email___________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please send:

All Records (Notes, Labs, Reports, CD)

or

Specific Item Only (please list):__________________________________________________________

**Depending on your request, it can take 2-3 weeks to receive records, though most requests are fulfilled sooner**

This authorization will not expire except when revoked by the patient, legal guardian, power of attorney, or healthcare surrogate. I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written request to the Medical Records Department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that once the information is disclosed, it may be re-disclosed by the recipient and the information may not be protected under federal privacy laws or regulations. I understand LSI will not condition treatment or payment based on this authorization or revocation of authorization unless otherwise allowed by law. A copy of this authorization may be utilized with the same effectiveness as an original. I am entitled to receive a copy of this authorization.

Signature of Patient/Guardian/Power of Attorney/Healthcare Surrogate

Date

Printed Name

Relationship to Patient if Applicable

Rev. 03.3.14

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