Authorization for Release of Records Value Specialty

AUTHORIZATION FOR RELEASE OF RECORDS

I hereby authorize Value Specialty Pharmacy to release information in its ﬁles relating to treatment and services provided to the following patient.
Patient Name

First NameLast Name
Patient D.O.B

MonthDayYear
Date
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Phone
Please enter a valid phone number.Format: (000) 000-0000.
Records pertaining to:

Select Medication
Records from:

MonthDayYear
Date
To

MonthDayYear
Date
Records should be sent to:
Name/Agency
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Signature
Relationship to Patient
Print Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Request

MonthDayYear
Date
Upload copy of patient/guardian Drivers License

Cancelof
Please verify that you are human
*If the request for release of records involves the records of a minor or an individual that is not yourself, please state your relationship to the patient, such as parent or guardian of the minor. If the release of records involves a minor, a birth certificate or other such documentation indicating legal parentage/guardianship is required for the release of records. Further, if the release of records involves a decedent or otherwise incapacitated person, a power of attorney, administrator of an estate, or other such legal documentation stating that the person signing this form on the behalf of someone else is legally authorized to do so, is required to accompany this form for the release of records.

Records will be released within 14 days of request in most cases. Should you require the records by a certain date, please contact the pharmacy after submitting the form.

Records will only be sent to recipient identified above and Patient/Guardian releases pharmacy of any records containing PHI that may be lost in the mail or viewed by any unauthorized person.

**This authorization expires one year after the date it was executed.
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AUTHORIZATION FOR RELEASE OF RECORDS