Informed Consent 

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Medical Records Release 

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS/PROTECTED HEALTH INFORMATION 

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This document must be signed by the patient or person authorized by law. 

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Transmission by facsimile or electronic means authorized to expedite transfer of records. 

I, Trevor Jones hereby authorizeMain Office and/or Thanapoom Boonipat MD to release the records identified on Exhibit A to this Authorization for Release of Protected Health Information. I agree to be responsible for all photocopying charges associated with the reproduction of such records. 

This Authorization for Release of Protected Health Information applies only to the release of the records identified on Exhibit A. Such records should be released to: name of recipient:  

address of recipient:  

for the following purpose(s):  

I understand that providing my authorization is voluntary. I need not sign this Authorization for Release of Protected Health Information to continue to receive healthcare treatment from Thanapoom Boonipat MD . I understand that I may revoke this authorization, in writing, at any time except to the extent that disclosure was made prior to the time I revoked this authorization. I further understand that I may inspect and receive copies of the information to be disclosed. 

I understand that the health records and information disclosed, or some portion thereof, may be protected by the Federal Health Insurance Portability and Accountability Act (“HIPAA”). I further understand that it is possible that the information described above may be re-disclosed by the recipient and may no longer be protected by HIPAA. I further understand that my records may be protected under state law and, if so, cannot be disclosed without my written consent unless otherwise provided for in the law and/or regulations. 

This Authorization for Release of Protected Health Information shall expire one (1) year from the date below. My signature below acknowledges that I have read, understand, and authorize the release of the information described on Exhibit A. 

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EXHIBIT A 

DESCRIPTION OF HEALTH INFORMATION SUBJECT TO 

AUTHORIZATION 

By placing a check-mark in the spaces below, I authorize the release of the following records pertaining to services 

from dates: (mm/dd/yyyy) to (mm/dd/yyyy) 

Complete medical record (all information) 

All hospital/institution records (includes nursing records/progress notes) 

Transcribed hospital/institution records (includes surgical reports, history/physical exam, consultation reports, discharge summary reports) 

Laboratory reports 

Pathology reports 

Diagnostic imaging reports 

Physical/occupational therapy reports 

Billing statements 

Physician office/clinical records 

Implant information (including operative report) 

Photographs 

Release of the following information may be governed by additional laws. I understand and agree that this information will be disclosed only if I place my initials in the applicable space next to the type of information: 

HIV/AIDS information  

Mental health information 

Genetic testing information  

Drug/alcohol diagnosis, treatment, or referral information