Augusta Health Care for Women

39 Beam Lane Fishersville, VA 22939

(540) 213-7769 fax (540) 213-7753

Authorization for Release of Medical Information

FMLA/DISABLITY FORMS

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(Print patients full name) Birthdate (Mo/Day/Yr)

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(Street Address) Social Security Number

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(City, State, Zip code) Phone

Do hereby authorize AHCFW

I understand that my health information may include general information related to my psychiatric health,

Drug/alcohol abuse, communicable diseases, abortion, or other information I may consider sensitive.

Information Release To: ______

Name of Company/Agency/Facility/Person

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Street Address

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City, State, Zip code

Reason for Leave ______Pregnancy ______Surgery ______Other ______

Please circle which Provider: Daniel B. McMillan, MD Lisa A. Bukovac, DO Betsy Cox, CNM

Cindy Almarode, FNP Christina E. Dubay, CNM Wendy Wimer, FNP-C

Please check one: ______FMLA ($5) ______Disability Forms ($10) ______Other ($10)

Patient picking up form ______Fax form Attention to ______Fax ______

(date)

I hereby authorize disclosure of the health information for the above named patient. This authorization is valid for 12 months from the date of signature. I understand that I may cancel this request with written notification and that it will not affect any information released prior to notification of cancellation. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal regulations. I need not sign this form to ensure healthcare treatment. Upon request, I will be given a copy of this authorization.

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Signature of individual or guardian Date

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Signature of Witness Date

*Note: $5.00 fee for completion of FMLA forms. $10.00 fee for completion of Disability forms.

$15.00 fee for completion of both FMLA and Disability forms.

Fees must be paid prior to the release of completed forms.

For office use only

Fee paid $______on ______.

Provider has given this amount of time off ______