Release of Information

Authorization for Release of Information – Compound Release

Name of Patient*

Date of Birth*

Southeast Radiation Oncology/Radiation Oncology of the Carolinas is authorized to release protected health information about the above-named patient in the following manner and/or to selected persons.

Check each method approved for communication

Then check type of information that can be given to person/entity using this communication method.

Voicemail Approval

Voicemail

Voicemail Communication Types

Financial
Medical

Email Communication

Email Address*

Email Communication Types

Financial
Medical

*For email communication to occur, please accept the disclosure below:

For email and/or text communication I understand that if information is not sent in an encrypted manner there is a risk it could be accessed inappropriately. I still elect to receive email and/or text communication as selected.*

The following person(s) is approved to receive information (provide name and phone number):

We are permitted by law, as outlined in our Notice of Privacy Practices and posted on our website at www.treatcancer.com to discuss your bill and payment arrangements with a family member, relative or close personal friend who is involved in your care or payment for that care.

Name

Phone

Communication Types

Financial
Medical
Both

Name

Phone

Communication Types

Financial
Medical
Both

Name

Phone

Communication Types

Financial
Medical
Both

Patient Rights

I have the right to revoke this authorization at any time by contacting our office.
I may inspect or copy the protected health information to be disclosed as described in this document.
Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.
Information used or 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 have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.

This authorization will remain in effect until revoked by the patient.

Signature of Patient or *Personal Representative (attach necessary documentation)*

Additional Documentation (if required)

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 512 MB.

Date*

Name

This field is for validation purposes and should be left unchanged.

Authorization for Release of Information – Compound Release

Check each method approved for communication

The following person(s) is approved to receive information (provide name and phone number):

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