I. PATIENT INFORMATION
- Title: (select one)
- [X] Mr.
- [] Mrs.
- [] Ms.
- [] Other
Luca
Middle Name: (optional)
N/A
Last Name:
Anderson
Gender: (select one)- [X] Male
- [] Female
30/04/2001
Address:
120 Alta Street, Alta, Los Santos
ZIP / Postal Code:
ANSWER
II. CONTACT INFORMATION
- Phone Type: (select one)
- [X] Mobile
- [] Home
- [] Work
- [] Other
34150865
Email:
[email protected] (( Jorgensen ))
III. RELEASE INFORMATION
- Purpose of Medical Information Release:
- [] Further Treatment / Continued Care
- [] Personal Use
- [] Attorney / Client
- [X] Other: (Work Mandatory eval)
- 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: 10/MAR/24
- To: 10/MAR/24
- 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)
- [] 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)
- [] Other Records: (specify here)
- I, [write your full name here], 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, Luca Anderson, 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, Luca Anderson, 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, Luca Anderson, 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, Luca Anderson, 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:
Date:
10/MAR/24
