-For Release Of Medical Information Form-

Authorization For Release Of Medical Information Form

Phone: 509-209-9033 | Email: info@pnwwoundspecialist.com
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Help us coordinate your care. Please identify the provider or organization and the records you want exchanged. This authorization is voluntary. You may ask questions or decline it; your treatment, payment, enrollment, or eligibility for benefits is not conditioned on signing this authorization.

Some treatment-related exchanges are permitted by law without an authorization. This form covers the specific exchange you authorize below and does not replace any separate permission required for specially protected records.
Your choice about this optional medical information authorization
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I authorize PNW Wound Specialist, LLC to:
Name/Organization
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid fax number.Format: (000) 000-0000.
Information to be Released/Obtained:

Other
Dates or time period of records to exchange
Enter a date range, a specific visit, or “all dates” within the record categories you selected.
Purpose of Disclosure:

Other
Sensitive Information Authorization
Optional permission for specially protected records
Authorization and your rights

I authorize the named releasing provider or organization to disclose the information selected above to the named recipient for the purpose I selected. For “Obtain Information from,” the named organization is the disclosing party and PNW Wound Specialist LLC is the recipient. For “Release Information to,” PNW Wound Specialist LLC is the disclosing party and the named organization is the recipient. I may choose one or both directions.

This is voluntary. Refusing to sign does not affect treatment, payment, health plan enrollment, or eligibility for benefits. I may revoke this authorization in writing by contacting PNW Wound Specialist LLC at 509-209-9033 to arrange secure delivery. Revocation does not undo actions already taken in reliance on it.

Information received by a recipient may be redisclosed and may no longer be protected by HIPAA; other applicable confidentiality laws may still protect it. This form does not authorize disclosure of psychotherapy notes or records protected by 42 CFR Part 2. Any required separate authorization or consent must be completed first. It does not authorize use of Part 2 records in proceedings against me.

This authorization expires one year after the date signed, unless I enter an earlier date below. I am entitled to a copy of my signed authorization. If a representative signs, staff must verify the representative’s legal authority.
Expiration Date (if different):

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient/Legal Representative Name:
Relationship and legal authority to sign (if representative)
For example: health care power of attorney or guardian. A relationship alone does not establish authority.
Patient or Authorized Representative Signature

Required only when you authorize the exchange. Staff will verify any representative’s legal authority.
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Authorization For Release Of Medical Information Form

Sensitive Information Authorization

Authorization and your rights