Release of Medical Records From Metamorphosis


Metamorphosis LTD

Authorization to Release Medical Records from Metamorphosis LTD

I hereby authorize Metamorphosis LTD, to release my Medical Records and/or MRI Imaging records to  

Patient’s Name: Phone number:

Address: Date of birth:

Fax Number records to be faxed to:  

Medical Records for Date(s) of:  

MRI Imaging and Area for Date(s) of:   

Health Information to being disclosed for the following purpose: (initial all that apply)

Change in Insurance or Healthcare Provider 

Continuation of Care

Initiation of Care

 Other 

I understand that this information shall be in effect for 180 days following the date of signature. Further, I may revoke this authorization at any time by giving oral or written notice to Metamorphosis. A photocopy of this authorization shall constitute a valid authorization. I realize once my medical records have been released to Metamorphosis, my revocation cannot be effective to the extent which the healthcare provider has taken the action with the reliance of this Authorization. I understand that the health information I am authorizing may disclose additional information regarding drug or alcohol abuse or psychiatric illness, and records of testing, diagnosis or treatment for HIV, HIV-related diseases and communicable disease-related information. I understand that Metamorphosis may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization. I have read this Authorization and I acknowledge being familiar and fully understand it’s terms and conditions. 

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Metamorphosis Pain Management https://www.metamorphosispain.com
Signature Certificate
Document name: Release of Medical Records From Metamorphosis
Unique Document ID: 906665919bca127f4290f5779cae3d6f70481602
Timestamp Audit
2017-05-07 22:36:33 MSTRelease of Medical Records From Metamorphosis Uploaded by Lisa Pearson - lisa@metamorphosispain.com IP 208.117.75.130