Authorization To Release Healthcare Information (Anthony Medical)

Authorization To Release Healthcare Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
RECIPIENT: I authorize my health care information to be released to the following recipient(s):*

Primary PhysicianSpecialty PhysicianPersonalOther
I was seen at the following clinic(s):*

Copperas CoveGeorgetownKilleenNorth WacoRound RockTaylorTempleWacoWest GeorgetownJarrell
Recipient:*
Phone Number*
Please enter a valid phone number.
Recipient Address*

Street Address

Street Address Line 2

CityState

Zip Code
PURPOSE: I authorize the release of my health information for the following specific purpose:*

To file for disability, VA benefits, or otherCoordination of care with my Primary Care Physician or Specialty PhysicianAuto AccidentPersonal UseOther
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*

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Date*

MonthDayYear
Date
Printed Name*

First NameLast Name
Relationship to patient*
Should be Empty:

Authorization To Release Healthcare Information

Initial the following statements