AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION
Patient Identification:
Printed Name
Date of Birth
/
Month
/
Day
Year
Date
Previously Used Name
Address
Home Telephone #
Cell Telephone #
Work Telephone #
Release Information To
Or Request Information From:
Type a question
Release To
Request From
Name of Person/Provider/Clinic to Whom info is being Released to/Requested from:
Business name of Provider if this release is for a medical provider
Relationship to patient if this form is for a friend or family member
Provider/Person Releasing info to Address
If you do not complete this there will likely be a delay to the processing of this document
Provider/Person Releasing info to Phone #
If you do not complete this there will likely be a delay to the processing of this document
Provider/Person Releasing info to Fax #
If you do not complete this there will likely be a delay to the processing of this document
Releasing To or From
To Identity Health Clinic
From Identity Health Clinic
Information to be released:
From (Date)
/
Month
/
Day
Year
Date
Beginning of Service
To (Date)
/
Month
/
Day
Year
Date
This Request and Authorization Applies to:
History & Physical Exams
Medication List
Psychiatric Reports
Discharge Summary
Clinical/Procedure Note
Complete Health Record
Treatment Plan
Laboratory Test Results
Demographics
Assessment/Evaluations
If None of the Above Apply please write in what you would like to allow to be released:
Purpose of records request (check all that apply)
Ongoing Treatment
Consultation
Collateral Information
Telephonic Communication
Diagnostic Clarification
Personal
Other
Expiration & Right to Revoke Authorization: I understand that at any time I may revoke this authorization by submitting a notice in writing to Identity Health Clinic. This authorization will expire 12 months from the date of which it was signed unless revoked earlier or at the following:
/
Month
/
Day
Year
Date (Do NOT Write Today's Date) - Best to Leave Blank
Terms: I understand that authorizing the disclosure of specified information is voluntary and completion of this form is not necessary to ensure treatment. I understand that the information in my record may include records relating to sexually transmitted diseases, drug and/or alcohol abuse and treatment, psychiatric care or other sensitive information.
Yes I understand
No - This Form is Void and Unusable
Disclosure: I understand that one the above information is disclosed, it may be subject to re-disclosure by the recipient and no longer protected by federal privacy laws or regulations.
Yes I Understand
No - This Form is Void and Unusable
Signature of Patient
*
Date
*
/
Month
/
Day
Year
Date
Legal representative - If patient has a Legal Representative/Guardian
Relationship of Legal Representative/Guardian to Patient
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