CNS / Cincinnati Neuro-rehabilitation Services Inc.
Speech Language Therapy
Pre-Registration
Medical Release
HIPAA
Photo Release
Medical Release

 

 

CNS   Cincinnati Neuro-rehabilitation Services, Inc.      speech-language pathologists

 10133 Springfield Pike, Suite D    ·    Cincinnati, OH  45215    ·     513/821-0110    ·    Fax 513/821-0757

 

 

 

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

 

Name:                                                                                                                                               

I, the undersigned, hereby grant my permission for release/ exchange of information relating to the care and education of the above captioned person, between Cincinnati Neuro- rehabilitation Services, Inc. and:

                                                                                                                                                          
                                                                      

The permission includes a release of information concerning HIV testing or treatment of AIDS, AIDS- related conditions, drug or alcohol abuse, drug- related conditions, and/or psychiatric/ psychological conditions.  The purpose of this release of information is to provide continuity of care, to assist in assessment and/or treatment, for processing an insurance claim, or to meet another need specified by me.

The following information may be released:

            Progress Note                                                            Educational Records

            Discharge Summary                                                 Court Records

            Entire Medical Record                                              History and Physical Examination

            X-Ray Report                                                             Mental Health/ Substance Abuse Records

                                                                                    

Treatment Dates:                                                                                                                                                  


The above information is to be released to:


Name                                                                                                                                                                       


Address                                                                                                                                                                   

City / State / Zip                                                                                                                                                      

Phone                                               


This statement must be signed and dated, and may be revoked at any time except to the extent action has been taken prior to revocation.  This consent will expire 60 days after the date below, or sooner by my choice, in which case this consent will expire on                               


I hereby state that I have read and fully understand the above statements as they apply to me.  I hereby consent to the disclosure of the treatment records to the person or institute and the purpose specified above.

 

Patient name                                                                                                        Date of Birth                            

Address                                                                                                                                                                   

City / State / Zip                                                                                                                                                      

Phone                                               

 

 

Signature                                                                                                                                   

 

                                                  (of patient or legal guardian)

Legal Guardian                                                                                                                         

                                                            (please print)

 



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