I. PATIENT INFORMATION
- Title: (select one)
- [X] Mr.
- [] Mrs.
- [] Ms.
- [] Other
JONATHAN
Middle Name: (optional)
D.N.A.
Last Name:
LI
Gender: (select one)- [X] Male
- [] Female
11/05/1982
Address:
1234 South Rockford Drive
ZIP / Postal Code:
D.N.A.
II. CONTACT INFORMATION
- Phone Type: (select one)
- [X] Mobile
- [] Home
- [] Work
- [] Other
68122683
Email:
[email protected] (( okcity ))
III. RELEASE INFORMATION
- Purpose of Medical Information Release:
- [] Further Treatment / Continued Care
- [] Personal Use
- [X] Attorney / Client
- [] Other: (specify here)
- 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: (specify here)
- Date Range:
I authorize the release of information covering the period(s) of treatment:- From: 15/NOV/2023
- To: 17/NOV/2023
- 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)
- [] Psychology Visits (Office notes, progress notes, procedure notes, evaluation results)
- [] Other Records: (specify here)
- I, [Jonathan Li], 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, [Jonathan Li], 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, [Jonathan Li], 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, [Jonathan Li], 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, [Jonathan Li], 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:
JLI
Date:
17/NOV/2023
