Transcription of AUTHORIZATION TO RELEASE MEDICAL …
{{id}} {{{paragraph}}}
AUTHORIZATION TO RELEASE MEDICAL INFORMATIONTO USMD PHYSICIAN SERVICESI, _____, hereby authorize(Name of patient or legal representative)to RELEASE the following information by mail, fax, electronically or orally to USMD Physician Services: information is for:_____(Name of person/entity who should RELEASE records)For the purpose of: _____(Address of person/entity who should RELEASE records)_____ Date_____ Expiration Date of Authorizationunless otherwise noted, AUTHORIZATION expires 1 year from date of signature aboveName of Patient: _____ Age:_____ Patient/Legal Representative Signature All Health information Statements of Charges or Payments AIDS or HIV information Initials _____ History and Physical Examination Copies of Records of Reports Provided to the Above Named ( Hospital, Lab, Clinic, etc.) Mental Health and/or Alcohol & Drug Abuse Treatment Initials _____ Dr. _____ Record of visit for a specific date(s). Specific dates include or are limited to:_____ Other (must be specific):_____ Progress Notes Substance Abuse Records Initials _____ Genetic information (inc.)
authorization to release medical information to usmd physician services i, _____, hereby authorize
Domain:
Source:
Link to this page:
Please notify us if you found a problem with this document:
{{id}} {{{paragraph}}}
For minor, Medical authorization, GUARDIANSHIP AUTHORIZATION, Medical, MINOR CONSENT TO MEDICAL TREATMENT, AUTHORIZATION TO RELEASE MEDICAL, Authorization, AUTHORIZATION TO DISCLOSE PROTECTED, AUTHORIZATION TO DISCLOSE PROTECTED HEALTH, Authorization for Release of Protected Health, Authorization for Release of Protected Health Information