Mt. Shuksan Family Medicine & Dermatology
AUTHORIZATION TO RELEASE MEDICAL RECORDS
Patient Name:
*
First Name
Last Name
DOB:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
INFORMATION TO BE RELEASED FROM:
Provider Name/Facility:
*
Street Address:
*
City, State, Zip Code:
*
Phone #:
*
Format: (000) 000-0000.
Fax #:
*
INFORMATION TO BE RELEASED TO:
Provider Name:
*
Facility:
*
Street Address:
*
City, State, Zip Code:
*
Phone #:
*
Format: (000) 000-0000.
Fax #:
*
INFORMATION TO BE DISCLOSED (CHECK ONE):
*
Most Recent (2 years) Medical Records
All Medical Records
Specific Information (Please Specify):
PURPOSE OF DISCLOSURE (CHECK ONE):
*
Transfer of Care
Coordinated Care
Attorney
Personal
PATIENT AUTHORIZATION:
I understand that my records may contain information regarding the diagnosis or treatment of HIV/AIDS, sexually transmitted diseases, drug and/or alcohol abuse, mental illness, or psychiatric treatment. I give my specific authorization for these records to be released. "EXCLUDE the following information from the records release (
please initial
):
Drug/Alcohol Abuse/Treatment
Sexually Transmitted Diseases
HIV/AIDS Virus
Mental Health/Psychiatric Disorders
MY RIGHTS: I understand I do not have to sign this authorization in order to obtain health care benefits (treatment, payment, or enrollment). I may revoke this authorization in writing. To view the process for revoking this authorization, please read the Privacy Notice to patients posted at the facility where your information is being released. I understand that once the health information I have authorized to be disclosed reaches the no ted recipient, that person or organization may redisclose it, at which time it may no longer be protected under Privacy laws.
Signature:
*
Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
(Patient, Guardian, or Authorized Representative)
This authorization will expire 90 days from the date signed
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