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Date of Birth
Above listed patient authorizes the following healthcare facility to make record disclosure:
City, ST, Zip
Dates and Type of information to disclose
2 years prior from last date seen
Specific Information Requested
The purpose of disclosure is
Change of Insurance or Physician
Continuation of Care (e.g., VA Med Ctr)
RESTRICTIONS: Only medical records originated through this healthcare facility will be copied unless otherwise requested. This authorization is valid only for the release of medical information dated prior to and including the date on this authorization unless other dates are specified.
I understand the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.
This information may be disclosed and used by the following individual or organization:
City, State, Zip
Please mail records.
Please fax records.
I understand I may revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing
and present my written revocation to the health information management department. I understand that the revocation will not
apply to information that has already been released in response to this authorization. I understand that the revocation will not
apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.