Incoming Release of Information Authorization

Incoming Release of Information Authorization

Use this form when you would like an outside facility or provider to send us your records.
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Chart Number
Other Name
Telephone Number *
Please enter a valid phone number.
Email
example@example.com
Address *

Street Address

Apt #

City State / Province

Postal / Zip Code
I authorize the following facility/facilities to disclose individually identifiable health information about me to:

Refuah Health Center
728 North Main St.
Spring Valley N.Y. 10977
845-354-9300 ext 1510
Facility 1 Name *
Facility 1 Number *
Please enter a valid phone number.
Facility 2 Name
Facility 2 Number
Please enter a valid phone number.
Facility 3 Name
Facility 3 Number
Please enter a valid phone number.
Periods covering:
From

Month Day Year
Date
To

Month Day Year
Date
Other, please specify:
Information is to be used for the purpose of: *

Continuing medical treatment
This authorization shall expire 6 months from the date of the request. This authorization may be revoked by me at any time by a written or verbal notice to Refuah Health Center, except to the extent that Refuah Health Center has relied o the authorization.
Refuah Health Center will not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization.

I understand that there is always the potential that information Refuah Health Center disclosed to a third party under this authorization could be redisclosed by that third party and no longer valid under this authorization.

I further understand specific type of information to be disclosed may, if applicable include: Psychological Treatment, Diagnosis, Prognosis and treatment for Acquired Immune Deficiency Syndrome, Aids Related Complex, or Human Immunodeficiency infection for any date of service.
Patient Signature *
Or Legally Authorized Representative
Date *

Month Day Year
Date
Relationship of Authorized Person
Should be Empty: