"*" indicates required fields AUTHORIZATION TO RELEASE MEDICAL RECORDSI authorize the release of medical record(s) of the above person. This information is being released to GEORGIA SPINE & ORTHOPAEDICS for purpose of continued medical care. “I understand that I have the right to revoke this authorization at any time by presenting a written revocation to the Medical Records Director or designee. I understand that the revocation will not apply to any information that has already been released in response to this authorization.” This expiration will expire one (1) year from the date of my signature. “I have read and understand the contents of this authorization and I confirm that the health care provider may use/disclose my protected health information to the persons and/or organization named above.” Please release to: Georgia Spine & Orthopaedics Dr. Erik Bendiks, Dr. Vinson Smith, Dr. Daryl Figa, Dr. Stanley Tao 11650 Alpharetta Hwy Roswell, GA 30076 Email: clinical@gaspineortho.com Phone: 404-596-5670 Fax: 404-334-0479Patient Name:* First Last Email* Date of Birth* MM slash DD slash YYYY Patient/Patient Representative Signature :*Date* MM slash DD slash YYYY