Colorado CyberKnife Doctor(s) List & Medical Records Release Authorization

1. Please provide us with a current list of doctors involved in your care.

Your First Name *This question is required.

Middle Initial

Last Name *This question is required.

Date of Birth (mm/dd/yyyy) *This question is required.

calendar

Primary Care Physician

Phone#

Medical Oncologist

Phone#

Neurologist/Neurosurgeon

Phone#

Surgeon

Phone#

Surgeon

Phone#

Other Physician

Phone#

Other Physician

Phone#

2. Imaging studies performed with regard to this condition

Date Performed (mm/dd/yyyy)

calendar

Location

Date Performed (mm/dd/yyyy)

calendar

Location

Date Performed (mm/dd/yyyy)

calendar

Location

3. Additional Information That Might Help Colorado CyberKnife Assist You:

4. I authorize the above named health care provider(s) to release information to Creekside Cancer Care, LLC DBA Colorado CyberKnife. The purpose for this release is continuance of care. Method of release shall be pertinent to the need and may include photocopies, fax copies, personal review, audio, video, electronic or verbal communication by appropriate practitioner. I understand that except for drug and alcohol treatment records, information disclosed under this authorization may be re-disclosed by the recipient and is no longer protected by privacy laws.

I understand that I may revoke this authorization at any time, except to the extent that action has already been taken place to comply with it. Without my expressed revocation, this authorization will automatically expire one year from the date of my signature.

A copy of this authorization (including a facsimile copy) may be used with the same effectiveness as the original.

Copy of Signed and Printed Signatures:
Submission of this form electronically requires the use of a digital signature. The Uniform Electronic Transactions Act, Colo. Rev. Stat. §24-71.3-101, authorizes Creekside Cancer Care, LLC DBA Colorado CyberKnife to accept digital signatures in place of manual signatures. Your digital signature on this form has the same legal effect as your manual signature.

Please type your name:

Please sign your name:

5. Signature Details

If Signed by Authorized Representative with Power of Attorney, Your Relationship to Patient:

Signature Date (mm/dd/yyyy) *This question is required.

calendar

Colorado CyberKnife Doctor(s) List & Medical Records Release Authorization

Page One