Hipaa Compliant Authorization For Release Of Patient Information Page 2

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Section III – Specific Information to be Released:
☐ Please release my Medical Record from (insert date) ____________ to (insert date) ____________.
☐ Please release my entire Medical Record, including patient history of treatment and/or transportation
and/or refusal of treatmenat and/or transportation including diagonstic records, medications lists, prior
medical history, electrocardiogram tracings and impressions, including any acceptance or refusal of care
and/or transportation for the abovementioned date(s).
Please release all billing records including all statements, insurance claim forms, itemized bills, records of
billing to third party payers and payment or denial of benefits for the abovementioned date(s).
Reason for release of information:
☐ At the request of the individual
☐ Other: __________________________________________________________________________
If an authorized representative is making this request, please provide your information below and attach
certifying documentation of your status as the authorized representative, such as a Power of Attorney
or Guardianship papers.
AUTHORIZED REPRESENTATIVE
Name:
Relationship:
Street Address:
Telephone:
City:
State:
Zip:
By signing this form, I am confirming that it accurately reflects my wishes. In addition, I have kept a
copy of this form for my records.
_______________________________________
______________________
Signature of Member or Authorized Representative
Date
State of Arizona
County of __________________________
The foregoing instrument was acknowledged before me this ____day of _______, 20___, at ______________,
Arizona, by ____________________________ to be his/her free act and deed.
___________________________________
Signature of Notary Public
Name of Notary Public (Print): _______________
Notary Public, State of Arizona
SEAL
My commission expires: _____________

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