Authorization To Release Healthcare Information
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
RECIPIENT: I authorize my health care information to be released to the following recipient(s):
*
Primary Physician
Specialty Physician
Personal
Other
I was seen at the following clinic(s):
*
Copperas Cove
Georgetown
Killeen
North Waco
Round Rock
Taylor
Temple
Waco
West Georgetown
Jarrell
Recipient:
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Recipient Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
PURPOSE: I authorize the release of my health information for the following specific purpose:
*
To file for disability, VA benefits, or other
Coordination of care with my Primary Care Physician or Specialty Physician
Auto Accident
Personal Use
Other
INFORMATION TO BE DISCLOSED: I authorize the release of the following health information: (check the applicable box below)
*
All my health information that the provider has in his or her possession, including information relating to any medical history, mental or physical condition and any treatment received by me.
Other
Other (if applicable)
Initial the following statements
I understand that Anthony Medical and Chiropractic Center / MBS Wellness Chiropractic Center / Waco Integrated Medical to disclose my personal health information to the listed.
*
I understand that I must pay a $25 processing fee for my personal health information. Medical record will be processed after payment.
*
I understand that Anthony Medical and Chiropractic Center / MBS Wellness Chiropractic Center / Waco Integrated Medical can take 7-10 business days after payment for the records to complete my request.
*
Patient Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Printed Name
*
First Name
Last Name
Relationship to patient
*
Submit
Submit
Should be Empty: