ROI From US
AUTHORIZATION TO RELEASE AND DISCLOSE PATIENT INFORMATION Sage Medical Clinic Phone 406-443-7733 Fax 406-443-8292
Patient Information
This information will be sent to your provider and will be kept as part of your patient records.
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Mobile phone number
Please enter a valid phone number.
Email address
example@example.com
City
State
ZIP
Clinic/Hospital/Health Care Provider
(Who has the information you want released?) Please list the specific Hospital and/or clinic Provider: Sage Medical Clinic. Address: 820 North Montana Avenue City: Helena State: MT Zip: 59601 Phone #406-443-7733 Fax #:406-443-8292
Receiving Party
(Where do you want the information sent?)
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax
Information to be Released
(What do you want sent or released? Check the appropriate box.)
Any and all records(include ALL types of record listed below.)
Yes
Only records types checked below
Discharge summary/note
History & physical exam
Laboratory reports
Pathology reports
Radiology reports
Immunization/allergy record
Consultations
Medication Reports
Operative Reports
Progress/clinic notes
Items in this section will be released unless checked
Physician’s Psychiatric Diagnoses
Alcohol and Drug Info/Treatment
AIDS/HIV/STD Testing and Results
Purpose of Release (Why is it needed?)
Continuing Care
Transfer of care
Personal Use or review
Other
This authorization lasts for one year after the date you sign it unless you enter a different date or expiration here:
Type a label
This authorization may be canceled in writing at any time. A cancellation will not change releases that happen before the cancellation.
Sage Medical Clinic will not restrict my treatment if I choose not to sign this authorization.
A photocopy/fax of this authorization will be treated in the same way as an original.
Sage Medical Clinic cannot prevent re-disclosure of your information by the person or organization who receives your records under this authorization, and that information may not be covered by state and federal privacy protections after it is released. By signing this authorization, you release Sage Medical Clinic from any and all liability resulting from a re-disclosure by the recipient.
Your signature indicates that you have read and understand this form, and authorize release of your information as described above.
Patient or Parent/Legal Guardian Signature
Date
-
Month
-
Day
Year
Date
Relationship
Submit
Should be Empty: