Authorization to Release/Obtain Patient Health Information

I hereby request that OrthoIndy (OI), 8450 Northwest Blvd., Indianapolis, IN 46278, obtain my health information in accordance with State and Federal privacy guidelines, as described below.

  1. The confidential health information may be obtained from the following individual or organization as mentioned in the form below.
  2. Information to be released:
    • Radiology/MRI Reports
    • Radiology Films/Digital Images
    • Other Info as mentioned in the form below.
  3. Unfortunately, we cannot review any images performed more than a year ago. The date(s) the information to be released was/were obtained is/are mentioned in the form below.
  4. Purpose of disclosure is to evaluate MRI/Radiology results.

This Authorization shall only apply to the data listed below.

I understand this consent can be revoked at any time except to the extent that disclosure made in good faith has already occurred in reliance on this consent. I further understand this information may be subject to redisclosure by the recipient and may no longer be protected by the HIPAA privacy guidelines.

This authorization is valid for sixty (60) days after the date of this request is made unless a different date, event or condition that would cause this authorization to expire sooner is indicated as follows:

Our MRI review is an informational review of the MRI report or images that you provide to us and is not a form of diagnosis. A diagnosis and a final determination of whether you may benefit from treatment at OI can only be made after you have been physically examined by our medical professionals. The MRI review has no value and will not be billed. MRI reviews are preliminary, and some patients’ individual medical conditions may require additional testing that OI may facilitate. Your personal health information may be shared with employees, providers, partners, affiliates, business associates or subsidiaries of OI. By completing this Authorization, you acknowledge that (1) the MRI review is only an informational review of the documents that you are providing; and (2) the information provided by OI is not a diagnosis. In addition, by completing and signing this Authorization, you authorize OI to obtain medical information from another facility regarding your MRI report and images. Further, you agree to release OI from any liability related to its review of the MRI report or images that you provide. OI makes no warranties or representations relating to the MRI report or images that you provide to us, including but not limited to, the authenticity, accuracy, or completeness of the MRI report or images that you provide.

I understand that I may contact a representative at OI at (317) 802-2000 regarding any questions about this Authorization or the MRI review.

By checking the checkbox and clicking the submit button on the Spine MRI Review form, you agree to the following statement:

I have read and understand the information provided in this Authorization. I understand that I may have a copy of this form after I sign it.