FORM #3 - AUTHORIZATION FOR DISCLOSURE TO RELEASE MEDICAL INFORMATION FORM

This notice describes how medical information about you may be used, disclosed, and how you can get access to this information.
  • Date Format: MM slash DD slash YYYY
  • Enter full name
  • Date Format: MM slash DD slash YYYY
  • I, the above named person (or the person’s legal guardian) request to release my health care information to:
  • Date Format: MM slash DD slash YYYY
  • I hereby authorize you to release to Temah Healthcare Services, LLC a copy of my medical records to be used for continuing medical care. I reserve the right to revoke this authorization in writing at any time and present the written revocation to the Medical Records Department. Further, I understand that this Protected Health information may be re-disclosed by the recipient and thus, no longer protected under the privacy rules. This release expires one year from the date signed. By my signature below, I understand that there are no limitations placed on dates, history, or illness, diagnostic and therapeutic information, including treatment of HIV, alcohol and drug abuse and psychiatric/mental health. I understand that authorizing the disclosure is voluntary.

     

     

  • Please include the Following Items

  • Other:___________________________________________________________

  • Enter full name
  • Date Format: MM slash DD slash YYYY
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