Authorization To Release Medical Information Form
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1FAMILY MEDICAL CENTER
•
•
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Joel G. Wright M.D.
Clinton D. Damron D.O.
Matthew R. Sampson M.D.
Trina S. Gomm FNP-BC
th
1492 S. 20
Avenue, Safford, AZ 85546 • Phone: (928) 348-2151 • Fax: (928) 428-3617
AUTHORIZATION TO RELEASE MEDICAL INFORMATION
PATIENT INFORMATION
SPECIFIC AUTHORIZATION FOR RELEASE OF
Name: _______________________________________
INFORMATION PROTECTED BY STATE OR
FEDERAL LAW:
Other Names Used: ____________________________
I specifically consent to the release of data and
Address: _____________________________________
information relating to: (check all that apply)
Substance Abuse (Alcohol/D.A.)
City, State, Zip: ________________________________
Mental Health (including psychological evaluation
Birthdate: _____________________________________
and treatment)
Telephone Number: ____________________________
HIV Related Information (AIDS related testing)
COPIES RELEASED FROM
Patient Signature: ______________________________
Date: ________________________________________
Name: ______________________________________
NOTICE: With respect to any substance abuse
Address: _____________________________________
treatment information, mental health records, and/or
City, State, Zip: ________________________________
communicable disease related information protected by
State and Federal law and released pursuant to this
COPIES RELEASED TO
authorization, the recipient understands that it is
prohibited from making any further disclosure of this
Name: ______________________________________
information without the specific written consent of the
patient, or as otherwise permitted by law/regulation.
Address: _____________________________________
This authorization shall be considered invalid after 6
City, State, Zip: ________________________________
months or 60 days with respect to State and Federally
protected records from the date of signature.
GENERAL INFORMATION
I may revoke this authorization at any time by providing
1. Type/Extent of Information
written notice of revocation. However, I may not revoke
the authorization retroactively for information already
All Records
released.
Selected Records Only (specific dates)
______________________________________
Patient Signature: ______________________________
Date: ________________________________________
2. Purpose/Need
If patient is unable to consent by reason of age or other
factors, state reasons:
Further Treatment
_____________________________________________
Insurance Reasons
Disability
Legally Authorized Representative:
Changing Physicians
Other: __________________________________
_____________________________________________
3. Specific Information (please list)
Relationship: __________________________________
_____________________________________________
_____________________________________________
Witness: _____________________________________
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