[RELEASE REQUEST] Daniella Estrella (now Farace)

[Danistars]

I. PATIENT INFORMATION

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• Title: (select one)
  • [] Mr.
  • [x] Mrs.
  • [] Ms.
  • [] Other
  First Name:
  Daniella
  
  Middle Name: (optional)
  
  
  Last Name:
  Estrella (Now Farace)
  
  Gender: (select one)
  • [] Male
  • [x] Female
  Date of Birth:
  04/08/1997
  
  Address:
  1115 Imagination Court
  
  ZIP / Postal Code:
  Los Santos, San Andreas
  

II. CONTACT INFORMATION

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• Phone Type: (select one)
  • [x] Mobile
  • [] Home
  • [] Work
  • [] Other
  Phone Number:
  436-9776
  
  Email:
  [email protected] (( MistressOfMayhem ))
  

III. RELEASE INFORMATION

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• Purpose of Medical Information Release:
  • [] Further Treatment / Continued Care
  • [x] Personal Use
  • [] Attorney / Client
  • [] Other

• Format of Medical Information Release:
  • [] Copy of Record to be picked up
  • [] Verbal Release (e.g. phone conversation)
  • [x] Electronical Release (sent via email)
  • [] Other:

• Date Range:
  I authorize the release of information covering the period(s) of treatment:
  • From: 01/01/2022
  • To: 05/06/2022

• Medical Records to be Released: (check all that apply)
  • [x] Emergency Room Visit (ER notes, progress notes, consultations, procedure notes, test results)
  • [x] Hospital Stay (History and physical, progress notes, consultations, operative reports, discharge summary, test results)
  • [x] Outpatient Surgery/Procedure (History and physical, progress notes, consultations, procedure notes, test results)
  • [x] Clinic, Office Visit or Immediate Care (Office notes, progress notes, procedure notes, test results)
  • [x] Psychology Visits (Office notes, progress notes, procedure notes, evaluation results)
  • [x] Other Records: ALL RECORDS
  
  

IV. AUTHORIZATION FOR RELEASE INFORMATION

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• I, [Daniella Farace], hereby authorize Pillbox Hill Medical Center to disclose my individually identifiable health information. I understand that this authorization is voluntary and I may refuse to sign this authorization. I further understand that my health care will not be affected if I do not sign this form.
  
  I, [Daniella Farace], understand that if the recipient authorized to receive the information is not a covered entity, the released information may no longer be protected by federal and state privacy regulations.
  
  I, [Daniella Farace], further understand that I may revoke this authorization at any time by notifying, in writing, the Pillbox Hill Medical Center facility where this authorization is being signed. I also understand the revocation must be signed and dated with a date that is later than the date on this authorization. The revocation will not affect any releases made prior to the receipt of the written revocation.
  
  I, [Daniella Farace], understand the record might not be complete, if it is a recent visit, and additional documentation could be added after submitting this request.
  
  By typing my name below, I, [Daniella Farace], certify that this information can be used for the purpose of processing my Authorization for Medical Records Release request. I consider this as my electronic signature for this request.
  
  

• Signature:
  DANIELLA FARACE
  
  Date:
  05/06/2022

[Naomi Finnemore]

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Dear Miss Farace

I've compiled all of the requested files from out archives and sent a copy to your registered address of residency ((Forum PM)). They shall arrive within a working week.

Kind regards,

Emilia Porter
Deputy Director
Pillbox Hill Medical Center