Asheville Neurology Specialists, P.A.

Authorization to Obtain Health Information

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Patient Information:

Name of Patient __________________________________ Date of Birth ___________
Address_____________________________________________________________

City, State, Zip _______________________________________________________

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Name & address of Covered Entity authorized to release information:

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Forward information to:

Asheville Neurology Specialists, P.A.

1200 Ridgefield Blvd., Ste. 250

Asheville, NC 28806

Telephone: (828) 210-9300 Fax: (828) 210-9319

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The information below will be used for patient care. Description of the protected health information to be disclosed and needed:

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This authorization shall be in effect until I revoke it; at which time this authorization to use or disclose this protected health information expires.

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Rights of the Patient

I understand that my treatment will not be conditioned on signing this authorization and that I have the right to refuse to sign this authorization. I understand that information disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.

I understand that I have the right to revoke this authorization by sending a written notification to the address below and that a revocation is not effective if the information has already been disclosed but will be effective going forward.

I understand that I have the right to inspect or copy the protected health information as described in this document. I can do this by written notification to the practice’s Privacy Contact at Asheville Neurology Specialists, PA, 1200 Ridgefield Blvd., Ste. 250, Asheville, NC 28806.

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Signature of Patient or Personal Representative

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Description of Personal Representative’s Authority (attach necessary documentation)