I. PATIENT INFORMATION
- Title: (select one)
- [] Mr.
- [] Mrs.
- [X] Ms.
- [] Other
Veronica
Middle Name: (optional)
Angelica
Last Name:
Escribano
Gender: (select one)- [] Male
- [X] Female
05/MAR/1985
Address:
5 Panorama Drive
ZIP / Postal Code:
10921
II. CONTACT INFORMATION
- Phone Type: (select one)
- [X] Mobile
- [] Home
- [] Work
- [] Other
02968885
Email:
[email protected] ((Jesu1)) (( Include forum name in brackets ))
III. RELEASE INFORMATION
- Purpose of Medical Information Release:
- [] Further Treatment / Continued Care
- [] Personal Use
- [] Attorney / Client
- [X] Other: Human Services & Welfare Request it for Adoption
- Format of Medical Information Release:
- [] Copy of Record to be picked up
- [] Verbal Release (e.g. phone conversation)
- [X] Electronical Release (sent via email)
- [x] Other: If possible; To be directly sent to Doctor Sade Aliz
- Date Range:
I authorize the release of information covering the period(s) of treatment:- From: 06/MAR/2024
- To: 12/MAR/2024
- Medical Records to be Released: (check all that apply)
- [] Emergency Room Visit (ER notes, progress notes, consultations, procedure notes, test results)
- [] Hospital Stay (History and physical, progress notes, consultations, operative reports, discharge summary, test results)
- [] 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: Check up/appointment records for Physicals
- I, Veronica A. Escribano, 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, Veronica A. Escribano, 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, Veronica A. Escribano, 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, Veronica A. Escribano, 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, Veronica A. Escribano, 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:
VEscribano/i]
Date:
12/MAR/2024