Patient Information Form - Green Valley Ranch Medical Clinic & Urgent Care (Page 3 of 6) in pdf

Patient Information Form - Green Valley Ranch Medical Clinic & Urgent Care Page 3

Green Valley Ranch Medical Clinic &Urgent Care

Authorization To Release Medical Records/Information

Physician/Institution/Agency

___________________________________________________________________________

Address_______________________________________City____________________ST_____________Zip____________

Telephone (____) _____________________ Fax (____) ______________________

I, Patient’s Full Name

___________________________________________________________________________________

Social Security #__________________________________ Date of Birth______________________________________________

Hereby authorize the party above to release information specified below to Green Valley Ranch Medical

Clinic/Urgent Care. I specifically authorize the use and disclosure of the following:

*Initial*

------- Release all medical records at this facility (or)

Release ONLY:

------- Drug Abuse, If any

------- Substance abuse, If any

------- HIV/AIDS, If any

------- Psychiatric and/or Psychological Conditions, If any

------- Only records generated by this facility (not including records received from other sources)

------- Only some portions of records maintained at this facility, specifically _______________________

________________________________________________________________________________

Please send my Medical Records to:

Green Valley Ranch Medical Clinic & Urgent Care

4809 Argonne St. Suite 100

Denver, CO 80249

Ph (303) 344-8700

Fax (303) 344-0200

I understand that I may revoke authorization at any time in writing. I understand that a copy of this

authorization may be utilized with the same effectiveness as an original.

________________________________

_________________

Patient/Legal Guardian

Date

Patient Information Form - Green Valley Ranch Medical Clinic & Urgent Care Page 3