Medical Records Release
Authorization to Release
Medical Information 541.773.3191 FAX 541.779.5647
Patient_________________________________________Birthdate__________________
I consent
to the release of Medical Information (records):
To: (Physician,
Clinic or Person) From: (Physician, Clinic or
Person)
773-3191
fax 779-5647 ______________________
Information to
be Released (initial to authorize release):
__________ History
__________ Operative/report/type operation
__________ X-rays/Radiographs reports
__________ Lab/Pathology Reports
__________ Other tests and studies as indicated
________________________________________________________________________
In addition to the general authorization to release medical records, I further authorize the release of the following information if it is contained in my medical record*: (initial to authorize release)
__________
Drugs and alcohol abuse
__________
Information related to diagnosis/treatment of HIV
*Please note that a separate release is required of
Behavioral Health Information
Purpose of Disclosure:
________________________________________________________________________________________________________________________________________________
This authorization is valid for six months after the date
of signature. The authorization may be revoked at any time (but not retroactive
to a release of information made in good faith) by the undersigned if providing
written notice of revocation.
___________________________________________________________ __________________
Signature
of Patient or Legally Authorized Representative Date