Request for Authorization For Disclosure of Health Information
With any questions, please contact Medical Records at 712-542-8302. Clarinda Regional Health Center Information: 220 Essie Davison Drive, Clarinda, Iowa 51632. Phone Number: 712-542-8302. Fax Number: 712-542-8346.
DateTime
Name
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First Name
Middle Name
Last Name
Date of Birth
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-
Month
-
Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
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-
Area Code
Phone Number
Release Information From:
Person and/ or Place
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Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Fax
*
-
Area Code
Phone Number
Release Information To
Person and/ or Place
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Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Fax
*
-
Area Code
Phone Number
Purpose for Release of Records (Check All That Apply)
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Continuing Care
Changing Physician
Moving
Personal
Discharge Summary
Insurance
Military
School
Information to be Released (Check All That Apply)
All
Physician's Notes
ER Reports
HIV/AIDS Testing and/or Treatment
Radiology Studies
H&P
EKG's
Operative Report
ER Reports
Discharge Summary
Other
Mental Health Records to be Released (Check All That Apply)
All
Psychiatric Evaluation
Psychological Evaluation/Testing
Clinical Intake Evaluation/Progress Notes
Written Report Regarding Treatment
Other
Dates of Service
*
All
Range (Input Dates)
Dates of Service
All
Range (Input dates below)
Date From
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Jan. 1, 2018
Date From
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Dec. 31, 2019
The following person(s) has permission to pick up my medical record:
Name
First Name
Last Name
Relationship
Name
First Name
Last Name
Relationship
I AUTHORIZE RELEASE OF ALL ALCOHOL AND/OR DRUG TREATMENT RECORDS THAT ARE PART OF THE RECORDS I SPECIFIED ABOVE UNLESS OTHERWISE INDICATED BELOW:
*
Do NOT release alcohol or drug treatment records protected under federal law
Release all information
I may revoke this authorization at any time by sending written notice to the facility/provider releasing records. A revocation is not valid is (1) action was previously taken in reliance on this authorization, or (2) if this authorization was obtained as a condition for obtaining insurance coverage. I authorize the facility/ provider to disclose medical information to the party identified in the "Release Information To" section. I understand this may include information regarding mental health, alcohol/drug use, and HIV treatment. I understand that once disclosed, information may be re-disclosed by the recipient and no longer protected. I understand this authorization is voluntary and that I may refuse to sign. Unless allowed by law, my refusal to sign will not affect my ability to obtain treatment, receive payment, or my eligibility for benefits. This authorization expires one year from the date of my signature unless I specify a different event, purpose or alternative expiration date below*
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By checking this box, I agree to the privacy policy stated above
Patient or Authorized Representative Electronic Signature
*
Relationship to Patient
If you are filling this out for yourself, type SELF
Today's Date
*
-
Month
-
Day
Year
Date
Please verify that you are human
*
Finish
Should be Empty: