Transcription of AUTHORIZATION FOR RELEASE OF PROTECTED …
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AUTHORIZATION FOR RELEASE OF PROTECTED …
DT0013L2549-IAN (08/12)Page 1 of 2 AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (PHI) Athens Regional Health Services, Inc. d/b/a Athens Regional Health System ( ARHS ) 1199 Prince Avenue Athens, Georgia 30606 PATIENT INFORMATION:_____ _____ _____ Name Date of Birth Social Security Number_____ _____ Street Address City, State, Zip Code _____ Phone Number I HEREBY AUTHORIZE ARHS TO:(Check one below)_____ RELEASE INFORMATION TO: _____ OBTAIN INFORMATION FROM.
DT0013. L2549-IAN (08/12) Page 2 of 2. Unless indicated by specifi c request checked below, I permit the release of any and all information including, if any, information concerning drug/alcohol abuse records, venereal disease and other
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