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. Name* First Last Date* Date Format: MM slash DD slash YYYY Social Security Number*Signature*Enter full nameDate* 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:Name* First Last Phone*FaxAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code For Purpose of*Date of Service* 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 ItemsPlease include the Following Items First Admission or ER notes Discharge Summary Operative Reports EKG’s X-ray Reports Face Sheet Progress Notes Third Choice Pathology Reports Consultation Notes Laboratory Notes/reports Stress Test Other:___________________________________________________________ Signature*Enter full nameRelationship*Date* Date Format: MM slash DD slash YYYY Name* First Last CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
