This document authorizes the release of a patient's protected health information from Brain & Spine Neurosurgical Institute to the specified recipient for the stated purpose. It specifies the patient's name, date of birth, information to be disclosed such as diagnostic studies, office notes, and dates of service. The patient understands they may revoke this authorization in writing at any time, and that it will expire in 120 days if no other date is specified.

1. Patient Name: _________________________________________ DOB: ___________
I hereby authorize the use and/or disclosure of the above named individual’s Protected Health Information as described in
this authorization. The PHI is to be released to:
Myself
Another Physician _____________________________________________
Other _______________________________________________________
For the purpose of ______________________________________________________________.
The information to be disclosed includes:
Diagnostic Studies
Laboratory Results
History & Physical
Operative Reports
Office Notes
Pathology Reports
Consultation Reports
Billing
Other _____________________________
Indicate the dates of service
25 Thurber Boulevard
Unit 6
Smithfield, RI 02917
_______________________________________________________________________________
Phone 401 404-2975
I understand that the information in my health record may relate to the re4sults of diagnostic tests used to determine if I
am infected by the human immunodeficiency virus (HIV), and/or treatment for mental health, alcohol or drug abuse.
Unless I have indicated otherwise above, I specifically authorize the release of this information.
Fax 401 404-2976
Satellite Locations
Attleboro, MA
Cumberland
East Greenwich
Johnston
Newport
North Smithfield
Wakefield
Westerly
Sumit Das, MD
Christopher Ottiano, MD
Katherine Williams, MD
I understand that I have the right to revoke (cancel) this authorization at any time. I understand that to revoke this
authorization, I must do so in writing. I understand that the revocation will not be effective until it is received, and it will
not apply to information that has already been released in response to this authorization. I understand that a revocation
will not apply to my insurance company when the law provides my insurer with the right to consent a claim under my
policy.
Unless earlier revoked in writhing, this authorization will expire on _______________________, or one hundred twenty
(120) days after it was signed if I fail to specify an expiration date or event.
I understand that signing this authorization is voluntary and that the Brain & Spine Neurosurgical Institute (BSNI) will
provide treatment and pursue payment for services regardless of whether I sign this authorization. If, however, my
treatment is related to a research study, or solely for the purpose of providing information about my health or medical
condition to someone else, BSNI may require that I sign this authorization before it provides treatment to me.
I understand that if I authorize BSNI to disclose information, the recipient of the information might disclose it to others,
and that any information disclosed by BSNI may no longer be protected by the federal rule on the privacy of medical
records.
Thomas Rocco, MD
Ronald Hillegass, MD
James Studders, MD
_________________________________________
Signature of Patient or Patient’s Legal Representative
___________________________________
Date
Christine Boyer, PA-C
Mohini Yalanis, RNP
___________________________________________
Printed Name of Legal Representative (if applicable)
____________________________________
Relationship to Patient