Authorization for Disclosure of Health Information

Authorization for Disclosure of Health Information
I hereby authorize Pinehurst Medical Clinic to release medical information from the records of:
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Patient Last 4 of SSN*
Patient Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date(s) of Treatment Requested:*
Progress NotesDischarge InstructionsX-Rays ReportsMedication RecordsOperative ReportConsultationsHistory and PhysicalLab ReportsEKG/ECG TestsOther
Continued Medical CareInsuranceLegalPatient’s Own UseOther
The Information May Be Disclosed To:
Recipient Name*
Recipient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Recipient Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Recipient Fax*
Please enter a valid phone number.Format: (000) 000-0000.
My refusal to sign this form will not adversely affect my ability to receive health care services, reimbursement for services, enrollment in a health plan or my eligibility for health benefits. However, information will not be released to the above-indicated recipient without my signature.

I acknowledge that the information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by Federal Law.

I have the right to revoke this authorization by written notice to the Healthcare Provider listed above. I understand that actions taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires on: Date
Or upon the following event: Type a label
(If no date or event is specified, this authorization will expire in twelve months from the date of signature).
I understand that the information in my medical record may include information relating to treatment of drug or alcohol abuse, mental health, sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), AIDS related complex (ARC) and/or human immunodeficiency virus (HIV).

PMC'S COPY SERVICE IS MRO AND CHARGES MAY APPLY
Patient/SelfParentLegal GuardianHealth Care Power of AttorneyAdministratorExecutor of EstateNext of KinBeneficiary
Requester Name

First NameLast Name
Requester Date of Birth

MonthDayYear
Date
Requester Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Requester Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Requester Email Address*
example@example.com
Signature*

Clear
Should be Empty:

Authorization for Disclosure of Health Information

The Information May Be Disclosed To: