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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 1 of 2 AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (PHI) Athens Regional Health Services, Inc. d/b/a Athens Regional Health System (“ARHS”)

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