Ohio Institute For Comprehensive Pain Management, Inc.

Mervet K. Saleh, M.D.

Board Certified Anesthesia

Board Certified Pain Management

1235 E. Alex Bell Road

Centerville, Ohio  45459

Tel. (937) 435-6400    Fax (937) 435-4793
 

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
 
I, the below identified person, do hereby authorize the release of my medical information, as indicated, between the following parties:
FROM:     TO:
       
       
           
I, authorize this release of information to entire verify services rendered to process a claim for benefits, to provide continuity of my medical care or as specified herein:.  I direct that all information obtained in association with this release be held in strict confidence by the recipient and further direct that it is not to be at any time by further disclosed without my specific written authorization. I understand that this authorization shall remain in effect for 60 days from the date that the individual signs this authorization. I understand, also, that except to the extent that the action has been taken based on my authorization, I may withdraw this authorization at any time by written notification to the parties involved.
 
It is my desire that only the information in my inpatient record,   clinic record,    emergency record and/or    ambulatory testing (please check appropriate box) indicated below is to be released as a result of this authorization:
       
 

Face Sheet

History & Physical

Discharge Summary

Consultation Reports

Radiology Reports

Laboratory Reports

Operative Reports

 

HIV Status

Pathology Reports

Physician Progress Note

Physician Orders

Therapy Reports

Emergency Treatment

Other specified here:

I am also making the following additional qualification: If the information specified above contains information related to treatment for drug and/or alcohol abuse or for psychiatric and/or mental conditions, or HIV test results or diagnosis, I am including this type of information to be included with other information to be released in association with this authorization.
 
First Name: MI: Last Name:
Address:        
City: State: Zip Code:
Soc Sec #     Date of Birth:
Dates of Treatment        
 
 

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(Date)                     (Patient/Guardian Signature)                                                     (Witness)
(Print the form before signing)