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:
This authorization if:
Limited to the following medical information:
This disclosure is being made for the following purpose(s):

Other
I also consent to the specific release of the following records:
Delivery Preference:
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:
Relationship (if other than the patient):
Patient’s Name:
Signature:
Patient’s Date of Birth:

MonthDayYear
Date
Should be Empty:

Authorization for Use & Disclosure of Medical Information