Authorization To Release Medical Information (Page 2 of 2) in pdf

Authorization To Release Medical Information Page 2

Authorization to Release Medical Information

Signature:

____________________________________________________________________________

(Patient/legal representative)

Date

Time

If signed by other than patient, indicate relationship:

__________________________________________

Witness: _____________________________________________________________________________

***********************For Office Use Only*******************************

Date Request Received: ________________________

Date Records Sent: _____________________

 Identity of individual and/or legal representative verified

Note:

______________________________________________________________________________

___________________________

_________________________________

Medical Record Number

Name of Staff Responding to Request

***********************Revocation of Authorization*******************************

In accord with provisions of the Notice of Privacy Practices, I hereby revoke the

 Above Authorization

 Authorization releasing information to ___________________________________________

 Authorization dated ______________________

Signature:

____________________________________________________________________________

(Patient/legal representative)

Date

Time

If signed by other than patient, indicate relationship:

___________________________________________

Witness: ____________________________________________

***********************For Office Use Only*******************************

Date Revocation Received: __________________________________

 Identity of individual and/or legal representative verified

____________________________

_____________

Medical Record Number

Clerk Initials

Retain original copy in Patient Record

Revised 6-2012

Authorization To Release Medical Information Page 2