Medical records | Brain Health USA

Authorization to release medical records (Admin Fees) *

Expedite 2 days / $50
Regular 3-5 days/ $25

Card

Name on Card

Total

$0.00

Name *

First

Last

Date of Birth *

Social security number (SSN) *

Information to be released to *

Name of Organization or individual

Email of organization/ individual *

Fax of organization or individual *

To release/exchange my medical/psychiatric records including any alcohol or drug abuse information *

The information is needed for: *

continued care by receiving facility/Doctor/therapist
claims settlement with insurance company
Legal proceeding or advise
Others

Signature *

Clear Signature

I authorize Ehab Yacoub MD inc. to release to the above information to the organization /individual. I have carefully read and fully understand this authorization. I realize that I must voluntary and knowingly sign authorization before any records can be released. I may refuse to sign and in the event the records cannot and will not reliance on it. If not previously revoked, this consent will terminate one year from the date written below. A photocopy of this authorization form is as valid as the original and is available upon request.

Signature of patient/parent/authorized representative *

Clear Signature

Probation on redisclosure: this information has been disclosed to you from records whose confidentiality is protected by federal law, federal regulation, (42 CFR, Part 2) Probation from making any further disclosure of this information with specific written consent of the person to whom it pertains. A general authorization for release of medical or other information if held by another part not sufficient for this purpose, federal regulation state that any person who violated any provision of this law shall be fined not more than $500 in case of the first offense, not more than $5000 in case of each subsequent offense.