| Release of Information | |
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Release of Medical Information
Patient Name:_________________________ DOB: _________ Patient Phone Number: ________________ Date Needed: ________ Please check one.
____ I, ___________________, authorize Cornerstone Medical Clinic to release my health information as designated below to: Name ______________________________ Phone Number __________
Address ___________________________ City _________________ State _____ Zip _________
____ I, ___________________, authorize __________________________ (medical facility) to release my health information as designated below to:
Cornerstone Medical Clinic
1825 Academy Drive, Anchorage, AK 99507
Ph 907-522-7090 Fax 907-522-7095.
Information to be released: For the purpose of: ____ Complete Record ____ Further Treatment ____ Clinic Records ____ Insurance Claims
____ Labs ____Workers Comp ____ Radiology ____ Legal Request ____ ER Reports ____ Personal Records ____ Billing Information ____ Other ___________ ____ Discharge Information ____ Other ______________
This consent is specifically for information created from services provided before the date of my signature. I acknowledge that the dates to be released may include material that references mental health ____, HIV ____, and drug/alcohol abuse ____ information. My initials authorize the release of this information as well. This release is subject to revocation at any time, except that the department that is to make disclosure has already taken action. If not previously revoked, this consent will terminate in 180 days. Printed Name: ___________________ Signature: _______________________ Relationship to Patient: ___________________ Date: ___________ |
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