I request health information be released from:
I request that health information be sent to:
Information to be released
Purpose of Access or Release
By signing below, I understand I am authorizing the use/release of my protected health information (PHI) and certify: My authorization is voluntary and the information given is accurate and complete to the best of my knowledge. This authorization is effective immediately and shall remain in effect for a period of one (1) year from the date of signature. I understand that I may revoke this authorization at any time by sending written notice, however, revocation will not affect any action previously taken in reliance on this authorization prior to receipt of my revocation. I further agree to release Micah 6:8 Ministries, Inc., its director, employees, and agents, as well as any facility honoring a request, from any and all liability resulting from the disclosure of the named patient’s medical records in reliance upon the authority contained therein.