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  • Release of Information

    1010 N. Thompson Street, Richmond VA 23230 

    Phone: (804) 358-6343

     

  • CONSENT TO RELEASE OR OBTAIN CONFIDENTIAL HEALTH CARE INFORMATION

  • Patient's Information:

  • Clinic Contact Information:

  • I, {legalFull}, hereby authorize Health Brigade to release or to obtain the health information indicated below that is contained in my patient record. I understand and acknowledge that this may include physical and mental illness, alcohol/drug abuse, genetics and/or HIV/AIDS test results or diagnoses.

    INDICATE APPROXIMATE DATE(S) OF SERVICE:


  • I understand that I have the right to take back this authorization, at any time, except when the release of records has already happened. I must submit this request in writing to the person who has my records. My removal of permission will not be effective until delivered in writing to the person who has my records. Information disclosed to someone who has received my records based on my permission can be re-disclosed by them and is no longer protected by federal privacy regulations. I understand that my health care and the payment for my health care will not be affected if I do not sign this form.

    This permission will end 12 months from the date of signature unless I write an earlier date here:

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  • ATTENTION: This is a legal document. Please read carefully. By signing, you agree that you understand and accept.

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