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  • Request/Authorization for Use or Disclosure of Health Information

    Completion of this document authorizes the disclosure and/or use of health information about you. Failure to provide all information requested may invalidate the authorization.
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  • Patient

    For protection of your privacy, we require a true, correct and legible copy of a valid government-issued photo ID that we may use to verify your identity. If you will be picking up your records in person, you will be asked to provide valid government-issued photo ID at that time, as well.

  • Patient Representative

    For protection of the patient's privacy, we require a true, correct and legible copy of your valid government-issued photo ID that we may use to verify your identity. If you will be picking up records in person, you will be asked to provide valid government-issued photo ID at that time, as well.

    In addition to your valid photo ID, please include a copy of the patient's valid government-issued photo ID, if applicable, as well as supporting documentation that gives you authority to request records on behalf of the patient. Acceptable forms of documentation include: death certificate*; executor of the estate (for deceased patients only); power of attorney (must include a provision that allows medical decision-making and/or release of medical records); power of attorney for health care (must include a provision that allows release of medical records); or other form of documentation, subject to review.

    *If a death certificate is the only supporting documentation provided, you (the patient's representative) must be listed on the death certificate.

  • Patient's Attorney

    For protection of the patient's privacy, we require a true, correct and legible copy of the patient's valid government-issued photo ID, as well as a complete and legible medical record information release (HIPAA) authorization form signed by the patient.

  • Court Order or Subpoena

    Include a true, correct and legible copy of the court order, or the valid subpoena for medical records and evidence that notification requirements have been met, if applicable.

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