ࡱ > a c ` 0 bjbj}} ` ` 0 X X X X X l l l l $ l . q q q $ z N ? X q O " q q q ? X X T m m m q X X m q m m m K| { . m j 0 m m X m q q m q q q q q ? ? q q q q q q q q q q q q q q q q : 606 N. 3rd Ave Suite 101 Scott Dunn, MD Sandpoint, ID 83864 Zach Halversen, MD Ph#208.263.1435 Dan Meulenberg, MD Fax# 208.263.4580 Hannah Raynor, MD www.fhcsandpoint.com Jeremy Waters, MD Kara Waters, DO Authorization To Release Medical Information Last Name: _____________________ First Name: _____________________ Date of Birth: ____/____/____ Requesting Records From: Family Health Center Release/Send Records To: ___________________________________________________________________ City: ___________________ State: ___ Phone #: ______________________ Fax #: _____________________ Information to be released: [ ] Last 4 chart notes [ ] Current medication list [ ] Colonoscopy report & pathology [ ] Last 4 lab results [ ] Mammogram & pathology [ ] Bone Density [ ] Pap Results [ ] Immunization record [ ] Other: __________________________________________ Purpose for which disclosure is being made: (Please check one of the following) [ ] Attorney [ ] Doctor [ ] Insurance [ ] Personal [ ] Other_______________________________________ Patient Authorization: I understand that my records may contain information regarding the diagnosis or treatment of HIV/AIDS, sexually transmitted diseases, drug and/or alcohol abuse, mental illness, or psychiatric treatment. I give my specific authorization for these records to be released. EXCLUDE the following information from the records released (please initial): _____Drug/Alcohol abuse/treatment & diagnosis _____Sexually Transmitted Disease _____Mental Illness or Psychiatric diagnosis/treatment _____HIV/AIDS diagnosis/treatment/testing I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment or my eligibility for benefits. I may inspect or obtain a copy of any information used/disclosed by this authorization. There may be a charge for these copies. I understand that I may revoke this authorization at any time by notifying Family Health Center in writing, but if I do it will not have any affect on any actions Family Health Center took before they received the revocation. I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure and no longer be protected under federal law. However, I also understand that federal or state law may restrict re-disclosure of HIV/AIDS information, mental health information, genetic testing information and drug/alcohol diagnosis, treatment or referral information. Please initial ONE option below: (If no option is chosen this will be treated as a one time request) ________ I understand that this authorization is valid for 1 year from the date signed OR, ________ I understand that this authorization is valid as a one-time request and if additional records need to be released I will need to sign another release of records request. ____________________________________________________ _____________________________ Signature of Patient or Patient Representative Date *Please provide documents to prove authority to sign on behalf of the patient. % 3 T u % & 5 C D E G t u ~ ööööⲮvl h+aC hY 5CJ h+aC hj 5CJ h h| h hY h h h hG hj h| 5h+aC h| 5CJ h| h+aC h5k CJ aJ mH nH uh+aC CJ aJ mH nH u"hIX h+aC CJ H*aJ mH nH u hIX h+aC CJ aJ mH nH uj h+aC UmH nH u' U 6 D F G t u c < = gd, gd dh gd