AUTHORIZATION FOR CELEBRATION PRIMARY CARE TO RECEIVE, ACCESS, AND USE HEALTH INFORMATION
Patient Information
Patient Name
*
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Phone
Format: (000) 000-0000.
Social Security Number
Records Requested By
Requestor Name
*
Records Requested From
Name of Facility / Organization / Person
*
Address
Phone
Format: (000) 000-0000.
Fax
Format: (000) 000-0000.
PLEASE FAX (preferred) OR MAIL THE HEALTH INFORMATION INDICATED BELOW: (check all that apply)
*
Entire medical record
Results of specific service(s), test(s), and/or prodcedure(s):
-> Laboratory results
-> Radiology Reports
-> Immunizations
-> Medications
Discharge Summaries
Procedure/operative notes
Specific date(s) of service(s) *please specify below
Other
Specific date(s) of service(s)
I authorizethe release of my STD results, HIV/AIDStesting, whether negative or positive, to Celebration Primary Care. I must give permission before disclosure of these results.
I authorize the releaseof any records regarding drug, alcohol, or mental health treatment to Celebration Primary Care.
PURPOSE OF RELEASE
Changing Providers
Moving
Personal File
Coordination of Care with Specialist or Agency
Life Insurance
Other
Printed Name of Patient or Legal Guardian
*
Relationship of Patient
Signature of Patient or Legal Guardian
*
Today's Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
This authorization expires 1 year from the date it is signed.
Submit
Should be Empty: