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    Sage Medical Clinic Phone 406-443-7733 Fax 406-443-8292 AUTHORIZATION TO RELEASE AND DISCLOSE PATIENT INFORMATION

  • Patient Information

    This information will be sent to your provider and will be kept as part of your patient records.
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  • Clinic/Hospital/Health Care Provider

    (Who has the information you want released?) Please list the specific Hospital and/or clinic)

  • Receiving Party (Where do you want the information sent?

    NAME: Sage Medical Clinic Address: 820 North Montana Avenue City: Helena State: MT Zip: 59601 Phone #:406-443-7733 Fax #406-443-8292

  • Information to be Released

    (What do you want sent or released? Check the appropriate box.)

  • This authorization lasts for one year after the date you sign it unless you enter a different date or expiration here:   

    • 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.
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  • Please review to ensure the details are correct before completion.

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