Mercy Grace Private Practice
Authorization to Release Medical Information
Mercy Grace Private Practice
Authorization to Release Medical Information
Patient Name
First Name
Last Name
Date of Birth
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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:
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.
To release all the above requested information relative to my treatment and care to:Mercy Grace Private Practice1720 E Boston ST., Suite 101, Gilbert, AZ 85295480-745-3702 / Fax 480-745-3709
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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