New Patient Medical History Form

Authorization to Release/Obtain Health Information
Patient's Full Name*

First NameLast Name
Patient's Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Social Security #*
I hereby authorize/request Urology Associates of Central MO to release and/or disclose medical information as indicated below to the health care provider, entity, or person I have indicated below.

Treatment, payment, enrollment, or eligibility for benefits will not be conditioned on my providing or refusing to provide this authorization.
The health information will be released and/or disclosed for the following purpose(s)*

Treatment/Continuing Medical Care (e.g. Other Healthcare Providers, Hospital, Physicians)Legal purposes (e.g. Attorneys)Personal UseBilling or ClaimsInsurance (e.g. life insurance application)Disability DeterminationSchoolEmploymentOther
Check the box for which type of information is to be released and/or disclosed:*

Entire Medical Record (Including Genetic Testing, Alcohol and/or Drug use or Sexually Transmitted DiseasesGeneral Medical Information (includes hospital and other facility records)Genetic Testing ResultsInformation regarding Specific Treatment (includes hospital and other facility records)Lab ResultsOther
What dates would you like released/disclosed?*
This Authorization Expires on/upon:*
Insert date or event that triggers expiration, not to exceed 1 year
I understand that my health information may be re-disclosed by the persons or organizations receiving my medical information, and that it may no longer be protected by federal or state privacy laws.

I understand that I may revoke this authorization at any time by notifying the disclosing party in writing. Written revocation will not affect any action taken in reliance on this authorization before the written revocation was received. I understand that if I want to cancel/revoke this authorization, I must mail/fax it to the address/fax number listed below or bring a letter in person stating that I want to cancel this authorization.
Patient's Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Signature*

Powered by Jotform SignClear
Date Signed

MonthDayYear
Date
If you are signing on behalf of a patient for whom you are the legal guardian or personal representative, you must attach a certified copy of your appointment as legal guardian or personal representative. If you are signing on behalf of a patient who is deceased, you must attach a certified copy of the patient’s death certificate.

Cancelof
Method Records to be released:*

Paper/MailFaxCD/Jump Drive (only certain records)Email (only certain records)
Would You like to us to release or obtain records?*

Release or mailObtain
Individual/Physician/Institution/Agency to release to/obtain from*
Email
example@example.com
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.
Should be Empty:

Authorization to Release/Obtain Health Information