Authorization for Release of Medical Records

I have engaged Caduceus International, LLC (“Caduceus”) to assist me in obtaining medical and/or treatment in the United States.  In connection with such engagement, Caduceus may receive medical information related to my condition.  I am executing this authorization (the “Authorization”) to allow Caduceus such access as is needed to facilitate its services to me in connection with my care.  Accordingly, I hereby authorize any and all of my medical providers of any kind or nature including without limitation its/their medical and administrative staff to disclose all medical and billing records of every nature pertinent in any way to any medical treatment rendered on my behalf to Caduceus.  I have engaged Caduceus to assist me in obtaining medical care in the United States.  This Authorization is executed to facilitate Caduceus in connection with its services.   This Authorization applies to all medical records as aforesaid, including, but not limited to, the following:

  1. All progress reports, clinical records, and summaries;
  2. Results of all laboratory tests, including, but not limited to, lab reports, x-rays and reports, ultrasounds and reports, CT Scans and reports, and MRI’s and reports;
  3. Records of all prescribed medications and treatments;
  4. All correspondence between my doctors andr their administrative staff or the administrative staff of all hospitals, clinics, or other medical treatment centers where I am, or have been, a patient or from whom I have received medical care;
  5. All correspondence between my doctors and their administrative staff or the administrative staffs of all hospitals, clinics or other medical treatment centers where I am, or have been, a patient or from whom I have received medical care;
  6. All statements rendered for medical services and supplies;
  7. All notes, correspondence or other records of any nature and by my physicians, nurses, or any other persons concerning me, my condition or my treatment; and
  8. All billing records.

 

This Authorization shall be deemed to comply with HIPPA and any other related law that may apply.  Accordingly, the minimum necessary requirement shall not apply to any uses or disclosures made pursuant to this Authorization.

 

The following person(s) or group(s) may receive and use the medical records authorized for disclosure above:

 

  1. Any person working for or with Caduceus to facilitate my travel to the United States or elsewhere for medical and/or treatment;
  2. Any third person retained or consulted by those working with Caduceus who may need access to my medical records.

The purpose of the requested disclosure is at the request of the undersigned client of Caduceus.

 

Important Information

 

I understand that this Authorization is voluntary and that I may revoke this Authorization at any time by submitting my revocation in writing to Caduceus International.  I understand that a revocation is effective only after it is received and verified and that a revocation will not be effective for use or disclosure of my medical records that was already made in reliance on my Authorization.  I understand that the medical records that are used or disclosed pursuant to this Authorization may no longer be protected by applicable privacy laws once they are disclosed and that the medical records may be subject to re-disclosure by the persons I have authorized to receive them.

I understand that I may refuse to sign this Authorization and that my refusal to sign this Authorization in no way affects my healthcare but may affect access to care through Caduceus.  I further understand that I am entitled to a copy of this Authorization upon my request.