Authorization for Release of Information Posted on April 23, 2025 by Coastal Carolina Otolaryngology Coastal Carolina Otolaryngology Authorization for Release of Information First NameLast NameDate of Birth MM slash DD slash YYYY Email CCOA is authorized to release protected health information about the above-named patient to the entities listed below.Entity(ies) to Receive InformationSpouse NameSpouse PhoneThis entity may receive health information about: Clinical information Billing information All Parent NameParent PhoneThis entity may receive health information about Clinical information Billing information All Other NameOther PhoneThis entity may receive health information aboutThis entity may receive health information about Clinical information Billing information All Information is not to be released to anyone but me If yes, check here VoicemailPlease call Home Cell Work If unable to reach me You may leave a detailed message. Please leave a message asking to return your call only I understand that I have the right to revoke this authorization at any time. I have the right to inspect or copy the protected health information to be disclosed asdescribed in this document. I understand that a revocation is not effective in cases where the information has already been disclosed, but will be effective going forward. I understand that information used or disclosed as a result of this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law. I understand I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.This authorization will be in effect until revoked by the patient.Signature (print full name)Date MM slash DD slash YYYY 3822 Mayfair Street, Myrtle Beach, SC 29577 | Phone: (843) 449-6449 1120 Glenns Bay Road, Suite 117, Surfside Beach, SC 29575 | Phone: (843) 215-1068
