Dr. Aaron Rickelman, Dr. Abbi Rickelman, Dr. Brady Dougherty
1360 NW 18th Street, Suite 101, Ankeny IA 50023
Phone: 515.957.4042 Fax: 515.598.7855
Authorization for the Release of Paitent Medical Records Form
This authorization will be effective for six months after the date signed, unless cancelled in writing. I understand that the cancellation will have no effect on information release prior to receiving the cancellation. A copy of this authorization is as valid as the original. If signing for a minor patient, I hereby state that my parental rights have not been revoked by a court of law.Notice to recipient of information:This information has been disclosed to you from confidential records, which are protected by law. Unless you have further authorization, laws may prohibit you from making any further disclosures of this information without the specific written consent of the patient or legal representative.Please indicate acknowledgement by clicking "Yes" below.Yes