AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
Only One Per Request

Patient Name

Patient Email

SS#

Date of Birth

is requesting that Serene Care Clinics, the practice identified above release health information (check one)

To the person/company/agency/facility listed below.

Obtain health information from the person/company/agency/facility listed below.

Name, Position, or Department:

Name of Organization:

Address of Organization:

Phone Number of Organization:

The information to be disclosed relates to service dates beginning (From)

The information to be disclosed relates to service dates ending (To)

The purpose of the disclosure: (“Request of the Individual” is sufficient for patient-initiated releases

Request of individual

Referral to Specialist

Continuing Care

Change of Doctor

Insurance

Workers Comp

Legal Investigation

CONDITIONS AND NOTIFICATIONS

This authorization for release of information expires 12 months from the date of patient’s signature. You may revoke this authorization at any time by writing to the Office Supervisor at the address listed above. However, such notification will not affect any actions taken in reliance on this authorization prior to the time of receipt of the revocation. You may inspect or request a copy of the health information to be used or disclosed, consistent with federal law. This authorization is being given to the SCC SCH group practice identified above and to SCC and each practice and entity affiliated with it.

Note:

There may be a processing fee charged to the patient to cover labor, copying, and supplies used to reproduce medical records

Signatures

I hereby authorize the use or disclosure of the personal health information as described above. I understand that I may refuse to sign this authorization, that this authorization is voluntary and that my health care and the payment for my health care will not be affected if I do not sign this form. I also understand that if the individual or organization authorized to receive the information is not a health plan or health provider, the released information may no longer be protected by federal privacy regulations and, therefore, may be subject to re-disclosure.

Electronic Signature of Patient/Personal Representative:

Date

TYPE Name of Personal Representative:

Relationship of Representative to Patient:

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
Only One Per Request

CONDITIONS AND NOTIFICATIONS

Note:

Location

Make an Appointment

Open Hours

Call Us

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATIONOnly One Per Request

CONDITIONS AND NOTIFICATIONS

Note:

Location

Make an Appointment

Open Hours

Call Us

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
Only One Per Request