Form 46096 - Authorization To Release Medical Information Form (Page 2 of 2) in pdf

Form 46096 - Authorization To Release Medical Information Form Page 2

For Office Use Only

Date Received: __________________________ Date Information Released: ____________________________

Copy of verification of identity of individual and/or legal representative obtained/filed.

Notes:_______________________________________________________________________________

____________________________________________________________________________________

___________________________

_____________

Medical Record Number

Clerk Initials

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: __________________________________________________

For Office Use Only

Date Revocation Received:____________________________________

___________________________

__________

Medical Record Number

Clerk Initials

Exceptions:

The exceptions noted in the Rights section on front of this form include: authorization for research; authorization for

health plan enrollment; and authorization solely for the purpose of creating protected health information for a third

party.

Adventist Medical Center, Portland, Oregon

AUTHORIZATION TO RELEASE

MEDICAL INFORMATION: OREGON

Page 2 of 2

Form 46096 - Authorization To Release Medical Information Form Page 2