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AUTHORIZATION TO RELEASE/OBTAIN PROTECTED …

Mail [ ] Pick-up [ ] AUTHORIZATION TO RELEASE/OBTAIN PROTECTED health information 1. I AUTHORIZE: 2. TO release TO: Name of sending person/organization Name of receiving person/organization Street Address Street Address City State Zip Code City State Zip Code I authorize the disclosure of my health and/or payment information ( PROTECTED health information ) noted below: (Check all that apply) D Attached Document D Immunization Records Only D Entire record for past three years (except for privileged D Lab report(s): Date(s) _____ information that requires a more specific AUTHORIZATION ).

Mail [ ] Pick-up [ ] AUTHORIZATION TO RELEASE/OBTAIN PROTECTED HEALTH INFORMATION . 1. I AUTHORIZE: 2. TO RELEASE TO: Name of sending person/organization Name of receiving person/organization

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