Authorization for Release of Information To/From SAMA HealthCare Services

Authorization for Release of Information To/From SAMA HealthCare Services
By my signature below, I hereby authorize my medical/health records or information to be released to/ from SAMA HealthCare Services for the continuity of my care.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1. I understand that I may revoke this authorization at any time by notifying the releasing Provider/Physician Facility in writing and the revocation will be effective on the date notification is received except to the extent action has already been taken in reliance upon my prior authorization.

2. I understand further medical care may be denied by the releasing Provider/Physicians/Facility following this release.

3. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by Federal privacy regulations.

IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT MEDICAL RECORDS AT (870)862-2400
My signature of that of my parent, legal guardian, or other authorized person*

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