Authorization for Release of Health Care Information from Pierce Street Same Day Surgery.
Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Email
example@example.com
Reason for Request
*
Continued Medical Care
Legal Purposes
Insurance Purposes
Personal Interest
Other
IF APPLICABLE - SPECIFIC AUTHORIZATION FOR RELEASE: I authorize the release of AIDS/HIV-related information which requires specific consent under federal law:
This consent is for the following Dates of Treatment (beginning)
*
-
Month
-
Day
Year
Date
This consent is for the following Dates of Treatment (end)
*
-
Month
-
Day
Year
Date
I authorize the release of the following records:
*
Complete Medical Record
Pertinent Documents
Lab Tests
Pathology Results
Radiology Images
Progress Notes
History and Physical
Operative Report
Billing Records
Other
Release Information to the Following
Name
First Name
Last Name
Organization Name
*
Delivery Method
*
Please Select
E-mail
Fax
Mail - USPS
Please include Email address, Fax number, or Mailing Address below based on selection.
Email Address
example@example.com
Fax Number
Format: (000) 000-0000.
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Consent
*
This authorization is valid for information already in existence and any information that may be generated while this authorization is effective. I understand that I can revoke my authorization at any time in writing. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. This authorization will expire in 12 months after the date it is signed. I understand that authorizing the disclosure of this information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that any disclosure of information carries with it the potential for unauthorized redisclosure and the information may not be protected by federal confidentiality rules. I have read this form, or it has been read and explained to me, and I understand its content.
Signature of Patient or, if applicable, Signature of Parent/Legal Guardian.
*
Date of Signature
*
-
Month
-
Day
Year
Relationship to Patient
*
Please Select
Patient
Parent
Legal Guardian
For Company Use Only:
Name of Employee Reviewing this Form:
Review Date
-
Month
-
Day
Year
Date
Submit Form
Submit Form
Should be Empty: