LibertyMedhealthgroup.com - Authorization to Release of Records

Authorization for Use & Disclosure of Medical Information
Patient Name:
DOB:

MonthDayYear
Date
This authorization allows the healthcare provider named below to release confidential medical information and records.

From: I hereby authorize: (Physician/Health Care Facility Requesting Information)

To release information regarding my medical history, illness or injury, consultation, prescriptions, treatment, diagnosis or prognosis, including x-rays, correspondence and/or medical records by means of mail, fax or other electronic methods.
To:
Address:
Requesting Following Medical Documents:

Medical History and Health Care RecordLaboratory ResultsRadiology ResultsHIV(AIDS)/Antibody Test Results and Diagnosis / Treatment Records
This authorization if:

Unlimited (all records, excluding substance Abuse, Mental Health, HIV Diagnosis/Treatment)Limited to the following medical information:
Limited to the following medical information:
This disclosure is being made for the following purpose(s):

Continuing CareTransfer of CareAttorney/Court CaseInsuranceWorkers Compensation CasePersonal ReasonsOther
I also consent to the specific release of the following records:

Drug/Alcohol/Substance AbusePsychiatric/Mental HealthTests for Antibodies to HIVHIV Diagnosis/TreatmentGenetic Information
Delivery Preference:

MailPick upFaxEmail
This authorization shall be effective immediately and remain in effect for one (1) year from the date signed. This informed consent is subject to revocation if any time by written notification only.

A copy of this authorization is as valid as the original. The undersigned has the right to receive a copy of this authorization.

I have been advised of my right to receive a copy of this authorization.
Signature of patient or legal/personal representative:

Clear
Relationship (if other than the patient):
Patient’s Name:
Signature:

Clear
Patient’s Date of Birth:

MonthDayYear
Date
Should be Empty:

Authorization for Use & Disclosure of Medical Information