AUTHORIZATION TO RELEASE MEDICAL INFORMATION TO INDIVIDUALS/FAMILY MEMBERS

  • In accordance with Federal government privacy rules implemented through the Healthcare Portability Act of 1996 (HIPAA), in order for your physician or staff of the Practice to discuss your condition with members of your family or other individuals that you designate, we must obtain your authorization prior to doing so. In the even of a critical episode or if you are unable to give your authorization due to the severity of your medical condition, the law stipulates that these rules may be waived.
    authorize the Practice to release any of all information concerning my medical care to any Individual except as set forth above.
    the Practice to verbally release any or all information concerning my medical care to the following individuals:
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Cardiac Specialty Care

• Structural Heart Disease
• TAVR
• CardioMEMS (Heart Failure)
• PFO Closure
• Coronary Intervention
• Complex Higher-Risk (And Indicated) Patients (CHIP) Angioplasty
• Atherectomy
• Impella and ECMO Support
• Peripheral Angioplasty
• Varicose Vein Treatment (Venous Ablation)
• DVT thrombectomy - IVC filter
• Carotid Stenting
• Rhythm Management
• Pacemaker
• Holter Monitoring
• Exercise Stress Test
• Echocardiography
• Nuclear Stress Test
• Enhanced External Counterpulsation (EECP)