Authorization to Release Medical Information
Mercy Grace Private Practice 1720 E Boston St. Gilbert, AZ 85295 P: 480-745-3702 F: 480-745-3709
Patient Name
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First Name
Last Name
(If applicable) Other names used:
First Name
Last Name
Date of Birth
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Day
Year
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Today's Date
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Purpose of Disclosure: Continued Patient Care
I authorize the release of records, including those which may contain confidential HIV/AIDS related information, confidential communicable disease related information, information relating to mental health and/or alcohol/drug abuse from the following facilities:
I hereby authorize Mercy Grace Private Practice to
Physician/Facility Name
I hereby authorize Mercy Grace Private Practice to:
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REQUEST medical records from Physician/ Facility listed below
RELEASE medical records to the Physician/ Facility listed below
Physician/ Facility Name:
*
Physician/Facility Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physician/Facility Phone Number
Please enter a valid phone number.
Physician/ Facility Fax Number
Please enter a valid fax number.
Information to be released:
Progress Notes
Lab results
Diagnostic Imagining Reports
Vaccine Records
Discharge Summay
Hospital Records
Other
Dates of service
:
to
Last Year
All Records
I understand that I may revoke this authorization at any time, except to the extent that action based on this authorization has already been taken. This consent will expire automatically one year from date of which is signed. Any disclosure of medical record information by the recipient(s) is not authorized except when implicit in the purposes of the disclosures. DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Patient Signature
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Parent / Legal Guardian Signature
First Name
Last Name
Date
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If patient is a minor and information is released regarding treatment for Alcohol and/or Drug abuse, both the patient and parent or legal guardian must sign.
Submit
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