Anchorage Medical Services - Release of Information Authorization Form
Patient Rights & Acknowledgments: I understand that I may revoke this authorization at any time by providing written notice. I understand that any revocation will not apply to information already released in reliance on this authorization. I understand that my treatment or payment cannot be conditioned on the signing of this authorization. I understand that once information is released pursuant to this authorization, it may no longer be protected under HIPAA privacy regulations.
Patient Name
Date of Birth
/
Month
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Day
Year
Date
Phone Number
Address
Address
Street Address Line 2
City
State
Zip
I hereby authorize AMS to obtain my medical records from
I hereby authorize AMS to release my medical records to
Myself
Other
Purpose of Disclosure
Continuity of Care
Legal
Insurance
Personal
Other
How Should Information Be Released?
In-Person Pickup
Email
Fax
Mail
Other
Enter Email Address
Enter Fax Number
Enter Mailing Address
Information to Be Released
Complete Medical Records
Chart Notes
Lab Reports
Radiology
Other
Chart Notes
All
Date(s) of Service
Lab Reports
All
Date(s) of Service
Radiology
All
Date(s) of Service
To disclose the following information, please initial below. HIV/AIDS related to health information, Mental health information, drug/alcohol diagnosis, treatment, and/or referral information.
This authorization will expire 365 days from the date signed or on the date picked below
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Month
-
Day
Year
Date
Signature
Today's Date
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Month
-
Day
Year
Date
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