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Authorization for Release of Records(Source: HIPAA Privacy Regulation 45 CFR 164.508)I, ___________________________________________________, hereby authorize the use or disclosure of my individually (print name of patient)identifiable health information and direct representatives of my medical care providers, including all physicians, chiropractors, hospitals, and clinics, to provide and furnish information and records regarding my medical treatment, including ALL medical and/or healthcare records from the date of first examination or treatment to the present date pertaining to the treatment, care, examination, evaluation, and/or transport for any condition, illness or injury, including, but not limited to ALL:NotesReportsChartsPhysical Therapy RecordsCorrespondence andLettersInvoices, Statements,BillsPatient History/Information SheetsX-rays, MRI’s, and allother Diagnostic FilmsInsurance Records and FormsTest Data, Resultsand ReportsTo an authorized representative of [Great American Insurance Company/Strategic Comp] upon delivery of a photocopy of this signed Authorization.The patient or the patient’s representative must read and initial the following statements:____1.I understand that this authorization will expire:(initials)____ automatically 180 days after the date of signing; or____ on ____/____/____ (month/day/year).____2.I understand that I may revoke this authorization at any time by notifying [Great American(initials)Insurance Company/Strategic Comp at P.O. Box 5789, Cincinnati, OH 45201] inwriting, but if I do it won’t have any affect on any actions they took before they receivedthe revocation.____3.I understand that any information that is disclosed pursuant to this authorization might be(initials)re-disclosed and potentially no longer covered by federal rules governing privacy of healthinformation.The purpose of this requested disclosure is to provide [Great American Insurance Company/Strategic Comp] with information and documentation concerning the patient’s past medical history in order to allow [Great American Insurance Company/Strategic Comp] to evaluate and investigate an insurance claim made by the patient. Please be assured that any information that is received pursuant to this authorization will be protected as required under state and federal laws.____________________________________ ___________________________________________(Signature of patient or patient representative)(Date) _______/_______/_______(Patient’s Date of Birth)____________________________________ _____________________________________(Printed name of patient’s representative)(Relationship to the patient)Post Office Box 5789 Cincinnati, OH 45201 800.467.7725 Fax: 855.277.6359 ................
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