wsfmed.com - Authorization to Disclose

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

IF A PATIENT WANTS ARCHIVED RECORDS SENT TO THEMSELVES, RECORDS WILL BE COPIED ON DISC AT A FEE OF $22.00. PRE-PAYMENT REQUIRED
Patient’s Full Name

First NameLast Name
DOB

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
1. Provider authorized to release Patient’s information, including: Name, Fax Number, Phone Number, and Address.
2. Provider authorized to receive Patient's information

Pavilion Family Medicine
1804 East Pavilion Place
Montrose, CO 81401
(970) 249-6670
Fax: 1-855-780-5041
3. The specific information that should be disclosed

ALL OFFICE NOTES/LABS/X-RAYSLAST 24 MONTHS OFFICE NOTES/LABS/X-RAYSOTHER (BE SPECIFIC IN THE BOX BELOW)
Pick upFaxedMailed
4. The purpose for the disclosure is
5. This authorization will expire on the following date or event
If no expiration date or event is listed, the authorization will expire one year after the date of the authorization.
Signature

Clear
Date

MonthDayYear
Date
Patient
Parent/Legal Guardian/POA
Should be Empty:

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION