I, ________________________________________, hereby authorize Dr. H. Berryman Edwards to release provide information about my diagnosis and treatment for insurance review as directed below: (Initial choice.)
____ Send a copy of my record. I understand there is no charge.
____Complete and send insurance company form or provide information by telephone. I understand there is a non-refundable $50 charge payable in advance.
This is not an urgent matter. I understand Dr. Edwards may honor this request within 5 business days of submission of this form and payment, if applicable, not including vacation time. I also understand that Dr. Edwards does NOT guarantee reimbursement for medication prescribed will be authorized and that in fact reimbursement is usually denied.
I understand that my express consent is required to release any health care information relating to testing, diagnosis, and/or treatment of HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health, or drug and/or alcohol use. If I have been tested, diagnosed, or treated for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health, or drug and/or alcohol use, Dr. Edwards is specifically authorized to release all health care information relating to such diagnosis, testing, or treatment.
I understand that authorizing Dr. Edwards to release my medical record to a third party may result in a waiver of my privilege rights or denial of medical, life, or disability insurance and that consultation with an attorney may be advisable.
The information specified may be released to:
I also authorize Dr. Edwards to discuss my treatment if appropriate. This released information may be used solely for insurance claim purposes. This authorization expires in 90 days from the date signed. It may be revoked at any time by written request.
Signed: _____________________________________ Date: ___________________________