AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION
Patient’s Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Previous Name(s):

First NameLast Name
First NameLast Name
Last four of your Social Security #:*
I request and authorize Bottumzup Health and Wellness, LLC to release healthcare information of the patient named above to:
Are records for your Primary Care Provider or Specialty?
What Specialty?
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Federal Regulation, 42 CFR Part 2, requires that a description of the amount, the kind of information that is to be disclosed and the purpose for this disclosure.
This request and authorization applies to:

All records availableAll correspondence
Or the specific records indicated here:

Lab WorkSchool EvaluationSummary of TreatmentHistoryMedicationsWork note
Other(specify)
And is to be released for the purpose of Continuity of care?

YesNo
Other(specify)
By checking the boxes below, I specifically authorize the voluntary release of the following types of medical records, if such records exist.
I authorize the release of my HIV/AIDS records, whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.

YesNo
I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above.

YesNo
Thisconsent to release is valid for one year, or until otherwise specified, andthereafter is invalid. Specify date,event, or condition on which permission will expire:
I understand that at any time between the time of signing and the expiration date listed above I have the right to revoke this consent at any time to the extent that information has already been released based on this authorization.
Patient Signature*

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Date Signed*

MonthDayYear
Date
Relationship to patient
THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED.
Should be Empty: