Medical Records Release

If you would rather fill out the PDF form and print it out to bring in with you, please download below.

Authorization for the Use and Disclosure of Protected Health Information

This authorization is required by the Health Insurance Portability and Accountability Act of 1996 to inform you of your rights to privacy with respect to your health care information.

I give permission to OGGI to release all records containing in my chart from Ohio Gastroenterology Group, Inc. including records received from other physicians or entities. I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse. I understand that by disclosing these records, the practice cannot guarantee the recipient will not re-disclose or use the records in a way that violates the privacy rules. Under the privacy rules, I have the right to revoke this authorization at any time in writing, and OGGI must cease using this authorization. However, the practice may complete any actions initiated with my PHI prior to my revocation which rely on the above records for completion. (An example of this would be that your insurance coverage may rely on these records to contest a claim). I must revoke this authorization in writing to: Ohio Gastroenterology Group, Inc. ATTN: Privacy/Security Board 3400 Olentangy River Road Columbus, Ohio 43202

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