Authorization Form

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Northern Colorado Orthopedic Associates

Sally A. Knauer, MD

Tania D. Pence, DO

Jane T. Servi, MD

Authorization Form

For Use and Disclosure of Health Information

1. Patient Information:

2. Records Released from:



Phone #:

Fax #:

3. Records Released to:

4. Information to be released:

All Records Patient Chart Notes Operation Reports Lab Reports MRI Reports X-RAY Films Other

5. Purpose of the Requested Disclosure:

6. Expiration Date/Event:

7. Right to Revoke:

I understand that I have the right to revoke this authorization in writing at any time subject to the exceptions stated below. To revoke this authorization, I understand that I must make my request in writing and clearly state that I am revoking this specific authorization. In addition, I must sign my request and then mail or deliver my request to:
Northern Colorado Orthopedic Associates, Attn: Privacy Officer
2121 East Harmony Road, Suite 290 Fort Collins, CO 80528

Exceptions to Right of Revocation:

I understand that my written revocation will not affect the ability of the physician's office to continue to use or disclose my health information to the extent that it has already acted in reliance on this authorization. For example, the physician's office cannot rescind disclosures it has already made, and may use my health information as necessary to bill and collect for services rendered.

8. Prohibition on Conditioning of Authorization

Northern Colorado Orthopedic Associates cannot condition treatment on your signing this authorization unless:
  • You are receiving research-related treatment; or
  • The only reason the physician's office is providing you with health care is to make a report to a third party, such as your employer (e.g., fitness to return to work) or school (e.g., P.E. physical).

9. Potential for Redisclosure:

Your health information disclosed according to this authorization will no longer be protected by the federal privacy law (known as "HIPAA"), and the recipient of the information may potentially redisclose it

10. This Authorization is Binding:

The statements made in this authorization are binding, controlling, and I understand that they take precedence over statements made in the physician's office's Notice of Privacy Practices.

11. Authorization Approval:

I hereby authorize the use or disclosure of the health information described in this authorization. I understand that if anyone who receives my health information is not a health care provider or a health plan, my health information may not be protected by federal privacy laws if my health information is redisclosed by that recipient person or physician office.