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
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:
------- 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


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