Authorization Torelease Medical Information To Dda Form

AUTHORIZATION   T O   R ELEASE   M EDICAL   I NFORMATION   T O   D DA  

PLEASE   R EAD   T HE   F ORM   C AREFULLY   A ND   F ILL   O UT   C OMPLETELY  

I   A UTHORIZE:  

_______________________________________________________________  

Name   o f   s ending   p erson/organization  

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Street   A ddress  

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City   S tate   Z ip   C ode  

INFORMATION   T O   B E   R ELEASED:  

Any   i nformation   i ncluding   t he   d iagnosis   a nd   r ecords   o f   a ny   t reatment   o r   e xamination   r endered   t o  

me.  

RECORDS   F ROM   T HE   T IME   P ERIOD:  

_________________________   t o   _ ________________________  

PURPOSE   O R   N EED   F OR   D ISCLOSURE:     C ontinuity   o f   m edical   c are  

AUTHORIZATION:I   u nderstand   t hat   t his   a uthorization   s hall   b e   v alid   f or   9 0   D ays.   I   u nderstand   t hat   I  

may   r evoke   t his   c onsent   f orm   a t   a ny   t ime   e xcept   t o   t he   e xtent   t hat   a ction   h as   a lready   b een   t aken.     I  

understand   t hat   a   r easonable   f ee   m ay   b e   c harged   f or   d uplication   o f   r ecords.   A n   e stimate   o f   t hose  

charges   w ill   b e   p rovided   u pon   r equest   p rior   t o   d uplication.  

_____________________________________________     _ ____________________________________  

    P atient’s   N ame   ( at   t ime   o f   t reatment)  

                                  P atient’s   D ate   o f   B irth  

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Street   A ddress  

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City/State/Zip   C ode  

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D aytime   P hone   N umber   ( s)

_________________________________________________________  

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    S ignature   o f   P atient   o r   R epresentative,   i f   m inor  

      D ate  

Please   f orward   t he   i nformation   t o   t he   f ollowing   o ffice   l ocation  

○   700 Geipe Road, Suite 230

○ 10710   C harter   D rive,   S uite   1 10

My   t reatment   w ith   D DA   i s   w ith   D r.   _ __________________________________  

On   _ ___________________________________  

  D DA Updated 3-2016