Authorization To Release Protected Health Information

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Jackson Regional Women’s Center
 
 
Authorization to Release Protected Health Information
I _____________________________________________________ give my authorization to release
protected health information to ________________________________________ who’s relationship to me
is __________________________________, if I am unable / unavailable to receive this information
concerning my medical record. If there are any other people you would like to authorize, please place their
name and relationship on the following lines:
Name:
Relationship:
Name:
Relationship:
___________________________________________
________________________
Printed Name (Patient)
Date
___________________________________________
Patients Signature
**I do NOT wish to assign anyone other than myself to receive information pertaining to my medical record.
__________________________________
___________________
Patient’s Signature
Date

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