Release of Information-TO

RELEASE OF MEDICAL INFORMATION CONSENT

Authorization to send health information to another clinic
Patient Name*
Address*

Street

Street Address Line 2

CityState

Zip
Phone Number ( )*
Date of Birth*

MonthDayYear
Date
Who are we releasing information to:
Name*
Address*

Street

Street Address Line 2

CityState

Zip
Phone Number ( )*
Fax Number ( )*
Reason for Request*
Please specifically indicate the information requested:*

All Medical RecordsOffice NotesImmunizations RecordsLabs
If Dr. Gould or his mid-level providers is requesting this authorization from you for our own use and disclosure or to allow another health care provider or health plan to disclose information to us:

We cannot condition our provision of services or treatment to you on the receipt of this signed authorization;

You may inspect a copy of the protected health information to be used or disclosed; and

You may refuse to sign this authorization

You have the right to revoke this Authorization at any time, provided that you do so in writing and except to the extent that we have already used or disclosed the information in reliance on this authorization.

Unless revoked earlier or otherwise indicated, this Authorization will expire in 365 days from the date of signing or shall remain in effect for the period reasonably needed to complete the request.

The information released has a potential for information to be re-disclosed by the person or organization to which it is sent. The privacy of this information may not be protected under the Federal Privacy Rule depending on whom the information is disclosed to.

Jim J. Gould, MD P.C. dba Mountain West Pediatrics, does not charge for the first ten pages of copies it makes of your personal health information

but does charge $0.10 per copied page after that.
Signature of Parent*

Clear
Relationship to Patient*
Date Signed*

MonthDayYear
Date
Should be Empty:

Who are we releasing information to: