Permission to Release Medical Records and Medical Information

PERMISSION TO RELEASE MEDICAL RECORDS AND MEDICAL INFORMATION

PLEASE FILL OUT THIS FORM CAREFULLY AND COMPLETELY. MUCH OF THE INFORMATION IS REQUIRED BY FEDERAL/STATE LAW IN ORDER TO COMPLY WITH YOUR REQUEST.

Patient’s Full Name______D.O.B______

Other Name Used______Phone #______

Current Address______City/State______Zip ______

PURPOSE OF RELEASE REQUEST

____CHANGE DOCTORS____DOCTOR CONSULTATION

____MOVING/RELOCATING____LEGAL REASONS

____SELF USE (patient/representative charged $25.00 for the first 10 pages and .25 for each additional page)

____OTHER Please specify:______

TYPE OF INFORMATION TO BE RELEASED—GENERAL MEDICAL INFO

Records from other medical facilities may not be included.

____LAB TEST RESULTS. ____IMAGING REPORTS (X-RAY, MRI, ETC)

____EC/EKG REPORTS____MEDICATION RECORD

____PROBLEM LIST____OPERATIVE REPORTS

____PHYSICIAN NOTES AND RECORDS (LIMITED TO 2 YEARS OF INFORMATON EXCEPT BY

VERY SPECIFIC REQUEST AND EXCLUDES OTHER PROTECTED RECORDS)

____OTHER. PLEASE SPECIFY EXACT INFORMATION AND DATES:______

______

I AUTHORIZE INFORMATION TO BE RELEASED FROM: (Please be complete and specific)

NAME OF FACILITY/PHYSICIAN______

STREET ADDRESS______CITY/STATE______ZIP______

I AUTHORIZE INFORMATION TO BE RELEASED TO: (Please be complete and specific)

NAME OF FACILITY/PHYSICIAN____Avoda Health, Amanda L. Brown, MD______

STREET ADDRESS____1050 SW 7th Avenue______CITY/STATE__Albany, OR______ZIP_97321__

EXPIRATION OF AUTHORIZED RELEASE (REQUIRED)

THIS PERMISSION IS VALID FOR 90 DAYS OR UNTIL______AND MAY BE REVOKED BY THE PATIENT ORALLY OR IN WRITING AT ANY TIME. IF SIGNING FOR A PERSON OVER 18 YEARS OF AGE, PROOF OF GUARDIANSHIP, POWER OF ATTORNEY, OR EXECUTOR OF ESTATE MUST BE PROVIDED.

DISCLOSURE STATEMENT (REQUIRED)

I UNDERSTAND THAT ONCE THE INFORMATION IS DISCLOSED PURSUANT TO THIS AUTHORIZATION, IT MAY BE RE-DISCLOSED BY THE RECIPIENT WITH THE KNOWLEDGE OR CONSENT OF THIS OFFICE OR YOU. THIS INFORMATION MAY NOT BE PROTECTED BY FEDERAL PRIVACY REGULATION.

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SIGNATURE OF PATIENT OR DATERELATIONSHIP TO PATIENT

LEGALLY RESPONSIBLE PERSON

DISCLAIMER (REQUIRED)

YOUR GENERAL MEDICAL INFORMATION MAY CONTAIN REFERENCES TO YOUR MENTAL STATE, DRUG AND ALCOHOL CONDITIONS, OR HIV STATUS OR SEXUALLY TRANSMITTED DISEASES. RELEASE OF THIS INFORMATION IN YOUR GENERAL MEDICAL RECORD REQUIRED ADDITIONAL AUTHORIZED SIGNATURES. WE MAKE EVERY EFFORT TO PREVENT RELEASE OF THIS INFORMATION. HOWEVER, WE CANNNOT GUARANTEE THAT EVERY REFERENCE TO THESE CONDITONS HAS BEEN REMOVED FROM YOUR GENERAL MEDICAL RECORDS.

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SIGNATURE OF PATIENT OR DATERELATIONSHIP TO PATIENT

LEGALLY RESPONSIBLE PERSON

AUTHORIZATION TO FAX INFORMATION

I SPECIFICALLY GIVE AUTHORIZATION TO FAX MY MEDICAL INFORMATIO. I UNDERSTAND THE RISK INVOLVED IN FAXING RECORDS AND CONFIDENTIALLY AT THE RECEIVING END CANNNOT BE GUARANTEED. ALL FAXED INFORMATION WILL CONTAIN A CONFIDENTIALITY STATEMENT AND INSTRUCTIONS FOR RETURNING MISDIRECTED INFORMATION.

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SIGNATURE OF PATIENT OR DATERELATIONSHIP TO PATIENT

LEGALLY RESPONSIBLE PERSON

ADDITIONALLLY PROTECTED MATERIAL

INFORMATION IN GENERAL MEDICAL RECORDS REGARDING MY MENTAL STATE, DRUG AND ALCOHOL CONDITIONS, SEXUAL ILLNESS AND HIV/AIDS

I RECOGNIZE THAT INFORMATION DISCLOSED IN GENERAL MEDICAL RECORDS MAY CONTAIN INFORMATION REGARDING MY MENTAL STATE OR BEHAVIORAL ISSUES, DRUG AND ALCOHOL CONDITIONS, SEXUALLY TRANSMITTED DISEASES OR CONTAIN INFORMATION REGARDING HIV/AIDS. I SPECIFICALLY CONSENT TO DISCLOSE SUCH RECORDS.

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SIGNATURE OF PATIENT OR DATERELATIONSHIP TO PATIENT

LEGALLY RESPONSIBLE PERSON

1050 SW 7th Avenue Ph: (541)928-5426

Albany, OR 97321 Fax: (541)928-6926 facebook.com/avodahealth