Ortho News

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Knee, Hip Replacement
Patients Recover Faster With Minimally Invasive Surgery

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Patient Name:

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S.S.#

Hereby authorize Orthopedic Specialists, S.C. to release copies of my medical records to the following:

REQUESTOR:

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REASON FOR RELEASE:

Change in Insurance Moving Changing Doctors/Leaving Practice

The following records will be released unless checked by the patient:

Alcohol and/or Drug Dependency HIV/AIDS Antibody test results and diagnosis treatment records

Mental health treatment records Other

I understand that only the last 5 years of physician's notes, x-ray reports and diagnostic test results will be released as well as the last year of laboratory results, unless otherwise indicated below:

Other permissions or restrictions

Prohibition or Re-disclosure: This information has been given to you from confidential records. You are prohibited from making disclosure of this information except with the specific written consent of the person to whom it pertains and the facility for which the information originates.

Date
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Signature of patient or authorized representative
(will be required at Doctor's office before records can be transmitted)

THE RELEASE OF THIS INFORMATION WILL BE SUBJECT TO A CHARGE