Patient Authorization For Release Of Medical Information printable pdf download

Patient Authorization for Release of Medical Information

This form authorizes the disclosure of protected health information, which may include confidential HIV-related information

Send

Physician__________________________________Address______________________________________

Medical

City____________________________________State___________Zip________________

Records

Phone____________________________Fax______________________________

to/from:

Patient Name________________________________Address____________________________________

City____________________________________State___________Zip_________________

Phone________________________________Date of Birth________________________

Information to be Disclosed:

Please send last TWO years of office visits, lab work and pathology.

Please include all surgeries and past pregnancies.

Include (Indicate by Initialing)

____HIV Related ____Behavioral Health ____Treatment for Alcohol

**This authorization may include disclosure of HIV, alcohol and/or drug abuse, and

mental health treatment ONLY if your initials are placed on the lines above. In the

event the health information described above includes these types of information,

and I initial the line above, I specifically authorize release of such information to the

person(s) indicated above.

Other (please specify)_

______________________________________________



Specific Date Range:

From______________________ To_______________________

Reason for Disclosure:

Primary Care/Specialist Patient Request Legal Proceedings

Transfer of Care



 Dr. Michelle Auerbach

 Village Medical Park

Send Medical Records

792½ North Main Street

 Dr. John C. Bowen

North Syracuse, New York 13212

 Dr. Melissa Brown

315.422.2222

315.701.3650 Fax

 Dr. James Brown, Jr.

 Jane Fields, CNM

 770 James Street

 Dr. Suchitra Kavety

Syracuse, New York 13203

to/from:

 Kandice Kowaleski, RPA-C

315.422.2222

315.472.8497 Fax

 Dr. Chris LaRussa

 Cheryl Luttinger, FNP-C

 4302 Medical Center Drive, Suite 302

 Therese Brown-Mahoney, NP

Fayetteville, New York 13066

 Dr. Fadi Makhlouf

315.422.2222

315.329.7224 Fax

 Elaine Mielcarski, CNM, NP

 Dr. Patrice Paolucci

 Medical Center West

 Dr. Eva Pressman

5700 West Genesee Street, Suite 9

 Dr. John Rosser

Camillus, New York 13031

 Dr. Neil Seligman

315.422.2222

315.488.8911 Fax

 Dr. Richard Waldman

Patient Signature:

______________________________________________ Date:__________________

Legal Representative: ______________________________________________ Date:__________________

Witness:

_____________________________________________ Date:___________________

Authorization will expire 12 months from the date of this authorization

AWM 033 Rev 06/15

PLEASE SEE THE BACK OF THIS FORM FOR IMPORTANT INFORMATION.

Patient Authorization For Release Of Medical Information

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