Release of Information

Authorization for Release of Information
Patient Information:
Legal Name*

First NameLast Name
Previous Names Used (if any)

First NameLast Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Provide the Name/Organization that Canopy Medical Clinic is authorized to exchange your medical information with. Please provide as much information as possible.
Name

First NameLast Name
Organization/Healthcare Facility Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid fax number.
I am requesting Canopy Medical Clinic:*

Send my medical information to the above contactReceive my medical information from the above contactBoth (typically use to collaborate/discuss care)
Records to be exchanged:*

Complete Medical Records for the Past 1 YearProgress NotesMental Health/Psych Testing and TreatmentMental Health Diagnostic AssessmentLab ResultsReferralOther (please describe below)
Please provide any instructions or additional information that is important for your request.
(List as specifically as possible, for example: name, dates of service, any documents).
Purpose of Release (select all that apply):*

Continuing/Transferring CarePersonal ReviewLegalInsurance/PaymentOther
Check box for approval to release information about HIV test results

I consent to release records with information about HIV test results.
Check box for approval to release information about substance use/chemical dependency records.

I consent to release records with information about substance use/chemical dependency records.
Send my medical records via (select all that apply):*

Fax (preferred)Mail (USPS, UPS, FedEx)Verbal CommunicationI will pick up at Canopy Medical Clinic
Delivery Method*
Note: For medical records over 20 pages, Canopy Medical Clinic charges a flat fee of $6.50. Payment must be received before records are released.
Consent*

I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time either orally or in writing. I understand that no disclosure of my records can be made without my written consent unless otherwise provided for in legal status and judicial decisions. I understand that authorizing the disclosure of this information is voluntary and I can refuse to sign this authorization if I so choose. I acknowledge that any disclosure of information carries with it the potential for re-disclosure and the information shared may not be protected by Federal confidentiality rules. By filling out this form, you authorize Canopy Medical Clinic to exchange my medication information with the Name/Organization/Person listed above. I understand that I have the right to inspect or receive a copy of the health information I have authorized to be used or released. I understand I have the right to receive a copy of this form if requested.
Signature*

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1411 32nd St S, Ste 1, Fargo, ND, 58103

Phone: 701-264-5200

Fax:701-999-2779

Email: info@canopymedicalclinic.com
Should be Empty:

Authorization for Release of Information

Patient Information:

Provide the Name/Organization that Canopy Medical Clinic is authorized to exchange your medical information with. Please provide as much information as possible.

Note: For medical records over 20 pages, Canopy Medical Clinic charges a flat fee of $6.50. Payment must be received before records are released.

1411 32nd St S, Ste 1, Fargo, ND, 58103Phone: 701-264-5200Fax:701-999-2779Email: info@canopymedicalclinic.com

1411 32nd St S, Ste 1, Fargo, ND, 58103

Phone: 701-264-5200

Fax:701-999-2779

Email: info@canopymedicalclinic.com