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Timothy Lane, M D - The Orthopaedic Institute

Timothy Lane, M D - The Orthopaedic Institute 2026

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The document is an authorization form allowing The Orthopaedic Institute and its Business Associate, Sharecare Health Data Services, to disclose a patient's protected health information to specified recipients. It includes sections for patient details, the purpose of the request, types of information to be released, delivery methods, and important legal disclaimers regarding the patient's rights and responsibilities. The form emphasizes voluntary consent and outlines potential costs associated with obtaining copies of health records.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your Patient Full Name and Date of Birth in the designated fields. Ensure accuracy for proper identification.
Fill in your Patient Address, including City, State, and Zip Code. This information is crucial for record delivery.
Provide a valid Phone Number and any Other Names you may have used. This helps in locating your records efficiently.
In the 'Release Information To' section, enter the email address of the recipient if you choose electronic delivery. Make sure it is legible.
Specify the Purpose of Request by checking one of the options provided: Personal, Treatment, Legal, Insurance, Transfer, or Other.
Indicate what Information to be Released by selecting from Office Notes, Labs, Operative Notes, or Diagnostic Reports. Specify Date(s) of Service if necessary.
Review the Authorization section carefully and provide your signature and date at the bottom to complete the form.

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