Authorization For Release Of Medical Information Form

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AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
The undersigned hereby authorizes
Dr.
and his/her associates to
copy and release to
Dr.
, and/or whose offices are located at
, any and all
records, charts,
and reports in your
possession
pertaining to all examination and treatment rendered to:
Name: ______________________________________
Date of
Birth:_________________________________
Social
Security
No.: ___________________________
A photostatic copy of this authorization shall have the same authority and effect as the
original.
Any
and all information may be released, including but not limited to mental health
records protected by the Lanterrnan-Petris-Short
Act,
drug and/or alcohol abuse records
and/or HIV test results, if any, expect as
specifically
provided below:
________________________________________________________________________
________________________________________________________________________
The information may be used only for the following
purposes:
________________________________________________________________________
________________________________________________________________________
__________________________
____________________________
Witness
Signature of Patient
Legal Decision Maker or Guardian
Date
This consent is valid for sixty (60) days, unless revoked by my written notice, provided
said notice is received prior to release of the above-designated information.
The patient, legal decision maker or guardian has the right to receive a copy of this form.
The signature above acknowledges that the following medical information may be
disclosed regarding; billing,
quality
assurance, transferring of patient records, benefits,
and patient requests.
• For the release of records 1) protected by the Lanterman-Petru-Short (LPS) or 2)
containing HIV test
results,
a separate authorization is required for each separate
disclosure. Further, the LPS Act often requires that both the patient and patient's treating
physician sign the authorization form before information may be
released.
If
patient finds any incomplete or incorrect information regarding any item or statement
in his or her
records,
the patient has the right to provide the health care provider a written
addendum regarding such item
or
statement.
Note:
To be valid, this authorization must be handwritten
by
the person who signs it or in
typeface no smaller
than 8-point
type,
it must clearly separate from other language on the
page and executed
by
a signature which serves no purpose other than to execute the
authorization
.

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