WHAR RECORDS RELEASE

WHAR RECORDS RELEASE
AUTHORIZATION FOR USE AND DISCLOSURE OF MEDICAL INFORMATION
I, FIRST AND LAST NAME herby authorize: Physician/Healthcare facility: From:From which facility (name of facility including address) to releaes information regarding my medical history, illness or injury, consultation, prescriptions, treatment, diagnosis or prognosis, including x-rays, Correspondence and/or medical records including those from my other healthcare provider that the above named healthcare provider may hold, by means of fax, or other electronic methods. To: Name of facility Street Address City State Zip Phone# Fax #
The medical Information/records will be used for the following purpose:
Type a question

Unlimited (all records, excluding Substance Abuse, Mental Health, HIV Diagnosis/Treatment) Limited to the following medical information:
List medical information:
I also consent to the specific releae of the following records (check all that apply):

Drug/Alcohol Substance abuse Psychiatric/Mental Health Tests for Antibodies to HIV HIV Diagnosis/Treatment Genetic Information
This authorization shall be effective immediately and remain in effect until:
Date
CHARGES

I understand that I may be charged for my records. I also understand that I can contact Professional Medical Copy at (530) 241-2971 for any questions regarding the associated fees for copying my records

RESTRICTIONS

Permissions for further use or disclosure of this medical information is not granted unless another authorization is obtained from me or unless such disclosure is specifically required or permitted by law. A photocopy or facsimile of this authorization shall be considered as effective and valid as the original.

I have been advised of my right to receive a copy of this authorization:
Patient Name: *
Date of Birth: *
Date

Month Day Year
Date
Signature of Patient or legal representative *

Clear
Name of Representative AND relationship if other than patient:
Should be Empty:

WHAR RECORDS RELEASE

AUTHORIZATION FOR USE AND DISCLOSURE OF MEDICAL INFORMATION