Kathleen Freeman
 
 
 Kathleen Freeman DOB: 86/05/19 (53 yo M) Acc No. 77711 Doc Name: 22/04/28 DMA Jones 
 DMA Authorization for Release of Health Information for Billing and Payment 
 Patient Name: Kathleen Freeman 
 Patient Address: 208 N Silver MAPLE Dr. Slid211 LA. 70458 
 Patient Social Security #: xxx.yy.zzzz 
 Phone # (111) 111-1111 
 Date of Birth: 86/05/19 
 1. The patient's health information may be disclosed to Diagnostic Management Affiliates, L.L.C. 
 ("DMA") or Diagnostic Management Affiliates - Preferred Provider Organization. L.L.C. ("DMA- 
 PPO"). (hereafter referred to as DMA) and to the attorneys for the patient who have been identified 
 by the patient as his/her attorney or who have a written engagement agreement to provide legal 
 services to the patient in connection with a personal injury claim of the patient. The information 
 disclosed may include the patient's health information and may include but is not limited to 
 medical records. billing records, reports, opinions. X-ryys. abstracts or excepts or any records, lab 
 reports. discharge summaries. history and physicals, consults, out patient reports, pathology reports. 
 physical therapy information and reports and emergency records and reports. The information 
 released may include information related to alcohol and drug abuse psychiatric, HIV and/or genetic 
 information. 
 I understand that a revocation is not effective to the extent that DMA has relied on the use or 
 disclosure of the protected health information. I understand that information used or disclosed 
 pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer 
 be protected by federal or state law. 
 My signature is an acknowledgement that I have received a copy of this authorization. 
 Date: 21/09/03 
 Signature of Patient or Legal Representative 
 Page 4 
 Rev. 21/06/05 
 File: DAIA Testing & Surgery Forms 
 Kathleen Freeman DOB: 86/05/19 (28 yo M) Acc No. 77711 Doc Name: 22/04/28 DMA Jones 
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