Nasseri Clinic of Arthritic and Rheumat

Authorization for Release of Protected Health Information to NCARD

Patient First Name:

Patient Middle Name:

Patient Last Name:

Date of Birth:

Street Address:

Phone:

City:

State:

Zip Code:

I hereby authorize the release of the protected health information (PHI) listed below to the Nasseri Clinics for dates of service from: to

The protected health information being authorized for release to the Nasseri Clinics may include the patient's complete medical history and all associated records pertaining to the services to be rendered at the Nasseri Clinics.

This protected health information may include any or all of the following:

Hospitalization Reports
Laboratory Reports

Operative Reports
Pathology Reports

Radiology Reports
Progress Notes

Exclusion of specific information from release of medical records:

Please exclude the following list from this release of protected health information.

Primary Reason for Request of Protected Health Information:

Changing physician
Legal

Consultation / second opinion
School

Insurance
Other: