Authorization for Release of Medical Information
I hereby authorize the release
of information from the medical record of:
Patient Name: _________________________________________________________________________________________
Date of Birth: ________________________________________________________________
Social Security No.: ___________________________
Information Release TO: G.
DeAn Strobel, MD,
Information Release FROM:________________________________________________________________________________________________
o Problem List |
o X-ray/CT/MRI reports |
o Progress Notes |
o X-ray/CT/MRI films |
o History & Physical Exam |
o EKG Reports |
o Lab Reports |
o Other Diagnostic Reports ____________________ |
o Immunizations |
o Other ______________________________ |
o Operative Reports |
o Pap Smears or Pathology Reports |
Please include information
(if applicable) pertaining to: mental health, drug/alcohol use, HIV/AIDS,
communicable disease treatment.
Purpose or need for disclosure of medical information:
o Continued patient care |
o Personal use |
o Attorney/Legal reasons |
o Insurance Claim/Application |
o Disability Determination |
o Other ___________________________________ |
I understand that
the information released is for the specific purpose stated above. Any
other use of this information without the written consent of the patient is
prohibited. I further understand that I may revoke this consent (in writing)
at any time except to the extent that action has been taken in reliance on
it. This consent will expire 90 days after the date of my signature unless
otherwise specified.
Signature of Patient or Legal Representative: ____________________________________________________________________________ Date: _____________________
Relationship to Patient ______________________________________ Witness: _________________________________________________
COMPLETE THIS SECTION ONLY
IF INFORMATION IS TO BE RELEASED DIRECTLY TO TIENT
I understand that my medical records may contain reports, test results, and
notes that only a physician can interpret. I understand and have been
advised that I should contact my physician regarding the entries made in my
medical record to prevent my misunderstanding of the information contained in
these entries.
I will not hold G. DeAn Strobel, MD, or Complete Women’s Care, , liable for any misinterpretation of the information in my medical record as a result of my not consulting the physician for the correct interpretation.
Signature of Patient or Legal
Representative: ______________________________________________________ Date:
_____________________
Date request completed _____________________________________________
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