I. PATIENT INFORMATION
- Title: (select one)
- [] Mr.
- [X] Mrs.
- [] Ms.
- [] Other
Minami
Middle Name: (optional)
/
Last Name:
Okada
Gender: (select one)- [] Male
- [x] Female
06/MAY/1987
Address:
390 Imagination Ct - Floor 1, Room 1
ZIP / Postal Code:
22101
II. CONTACT INFORMATION
- Phone Type: (select one)
- [X] Mobile
- [] Home
- [] Work
- [] Other
58282157
Email:
[email protected] ((Justin Kolk)) (( Include forum name in brackets ))
III. RELEASE INFORMATION
- Purpose of Medical Information Release:
- [] Further Treatment / Continued Care
- [] Personal Use
- [] Attorney / Client
- [X] Other: (Personal and work.)
- Format of Medical Information Release:
- [X] Copy of Record to be picked up
- [] Verbal Release (e.g. phone conversation)
- [X] Electronical Release (sent via email)
- [] Other: (specify here)
- Date Range:
I authorize the release of information covering the period(s) of treatment:- From: 01/JAN/2023
- To: PRESENT
- 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)
- [] Clinic, Office Visit or Immediate Care (Office notes, progress notes, procedure notes, test results)
- [] Psychology Visits (Office notes, progress notes, procedure notes, evaluation results)
- [] Other Records: (specify here)
- I, [Minami Okada], 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, [Minami Okada], 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, [Minami Okada], 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, [Minami Okada], 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, [Minami Okada], 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:
mOkada
Date:
01/JUN/2023