Authorization For Use and Disclosure of
Protected Health Information

Patient Name

Information to Be Used or Disclosed

The information covered by this authorization includes:

All medical records Office notes Inpatient records Discharge Summary Reports of tests and xrays Outpatient records Face Sheets with Final Diagnosis Emergency room records Abstracts Procedures and Complications Consultation reports Physical therapy History & Physical Records Outpatient clinic notes Other

Other

Purposes of Disclosure

Information listed above will be disclosed for the following purposes:

For my doctor’s information For designated persons information Other

Other

Persons Authorized to Use or Disclose Information

Information listed above will be used or disclosed by:
MICHAEL W. GOODMAN, M.D.

Persons to Whom Information May Be Disclosed

Information described above may be disclosed to:

Spouse

Son/Daughter

Friend

Doctor

Other Relationship

Date of Authorization

From

Through

Right to Terminate or Revoke Authorization

This authorization may be revoked at any time by submitting a written revocation to MICHAEL W. GOODMAN, MD, P.C., 979 E. Third Street, Suite C-0630, Chattanooga, TN 37403. You should contact the Privacy Officer to terminate this authorization.

Patient or Representative

Rationale for serving as Patient Representative (if applicable)

Date Accepted

Patient Date of Birth

Patient Social Security Number

Our Location

Erlanger Medical Mall
979 East Third Street
Suite C-0630
Chattanooga, TN 37403
423.267.5677

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More Info

If you need additional information, please call us at (423) 267-5677, or send an e-mail to info@goodman-gi.com.

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Authorization For Use and Disclosure of Protected Health Information

Information to Be Used or Disclosed

Purposes of Disclosure

Persons Authorized to Use or Disclose Information

Persons to Whom Information May Be Disclosed

Right to Terminate or Revoke Authorization

Our Location

HealthGrades.com

More Info

Authorization For Use and Disclosure of
Protected Health Information