First Name
Middle Initial
Last Name
Email
Street Address
City
State
Zip Code
Date of Birth
Gender MaleFemale
Preferred Phone
Name (Health Care Provider)
Phone
Date(s) of service to release:
Discharge SummaryHistory & PhysicalProgress/Office NotesConsultationOperative ReportPathology ReportLaboratory ReportECG/EEG/Cardiac CathRadiology ReportEmergency ReportNursing NotesEntire RecordOther (Specified below) Other specified:
This authorization is for FULL DISCLOSURE OF ALL RECORDS, including clinical findings, diagnosis, treatment, assessment, recommendations for further care, name of health care personnel, dates of hospitalizations and ambulatory visits, charges, and any information that may be related to drug, alcohol, psychiatric conditions, and/or sexually transmitted disease, including HIV/AIDS information. Such records will be disclosed unless specified information to exclude is listed below.
Exclusions:
Continuing TreatmentLegal InvestigationInsuranceDisability DeterminationWorkers' CompensationPersonalOther (Specified below) Other specified:
I understand that the recipient of this information may not use or disclose the medical information unless another authorization is obtained from me or unless such use or disclosure is specifically required or permitted by law.
If signer is other than Patient, please indicate legal authority.
GuardianParent of MinorAttorney in FactNext of KinExecutor of EstateOther Other specified:Upload Legal authority documentation (pdf, jpg or png):
Patient is: MinorIncompetentDisabledDeceased
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