Release of Information

Name*

First NameLast Name

Date of Birth*

Date

Primary Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Request*

Release expires one year from date of request.

Your Provider at Lakeside Clinic, LLC:*

Name of Provider or Facility*

Facility Address (if full address is unknown, please fill out City and State)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Facility Phone Number*

Please enter a valid phone number.

Facility Fax Number

Please enter a valid fax number.

Type of Records Requested:

Specific Illness or Injury and/or Date(s) of Service

By signing this document, I understand that:

My right to healthcare treatment is not conditioned on this authorization.
I may cancel this authorization at any time by submitting a written request to Lakeside Clinic, LLC, 2337 Homer Clayton Drive, Guntersville, AL, 35976, except where a disclosure has already been made in reliance on my prior authorization.
If the person or facility receiving this information is not a health care or medical insurance provider covered by privacy regulations, the information stated above could be redisclosed.
Release of HIV-related information, mental health related care, or substance abuse diagnosis and treatment information requires additional authorization.
There may be a charge for the requested records.

Signature of Patient or Legal Representative*

If signed by legal representative, relationship to patient:

Today's Date*

Date

Authorization for Release/Request of Protected Health Information