• Authorization to Release Medical Information

  • PATIENT INFORMATION:

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  • MEDICAL INFORMATION RELEASED TO:

  • MEDICAL INFORMATION REQUESTED FROM:

  • PURPOSE OF THE DISCLOSURE:

  • METHOD OF DELIVERY:

  • A photo ID is required to pick up records.

  • SENSITIVE MEDICAL INFORMATION TO BE RELEASED (Patient or Patient Representative Initial and Date Required for Each Item):

    I understand that the records requested above may contain sensitive medical information that requires my specific consentinorderto

    be released. I specifically authorize the release of the following sensitive medical information:

     

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  • PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY:

    • I understand that this authorization is voluntary and I may refuse to sign it. The immediate consequences of my refusal will be that DBDT, LLC will not receive or release the medical information listed above through this authorization. I understand my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.
    • I understand that I may revoke this authorization, at any time, by notifying the DBDT, LLC in writing at the address listed above. I understand my written revocation is effective only when DBDT, LLC receives it. I understand that my later decision to revoke this authorization will not affect any action, use, or  disclosure in reliance on this authorization, which cannot be reversed.
    • I  understand I have the right to inspect and/or receive a copy of the medical information listed above and also receive a copy of this authorization form.
    • I  understand that medical information disclosed through this authorization may no longer be protected by federal health information privacy laws. I also understand that sensitive medical information (identified above) disclosed through this authorization may require my additional authorization to be further disclosed.
    • I understand this authorization will terminate ninety (90) days after my date of signature and will not be able to be disclosed beyond this date.
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