Authorization to Release Confidential Health Information

I HEREBY AUTHORIZE: Ο Dr. Katrina Iiams-Hauser, ND

Ο Facility/Doctor’s Name:_______________________________________________________________________




TO RELEASE: Ο Complete Chart Record (does not include billing information or radiographic images)

Ο Chart Notes: Ο All Ο Specify:___________________________________________________________

Ο Labs/Reports: Ο All Ο Specify:___________________________________________________________

Ο Billing Records: Ο All Ο Specify:__________________________________________________________

Ο X-rays/Radiographic Images (specify):___________________________________________________________

Ο Other:_____________________________________________________________________________________

FROM THE HEALTH RECORD OF: Name:____________________________________________________________

DOB:____________Soc. Sec. Number:___________________Daytime Phone:__________________ext.:_________

Are you releasing your own records: Ο Yes Ο No

If not, what is your relationship to the patient?_______________________________________________________

TO BE RELEASED TO: Ο Patients for Patients Medical Ο Self (please provide current address below)

Ο Facility/Doctor’s Name:_______________________________________________________________


Phone:___________888-204-1260________________ Fax:____________888-204-1280______________

FOR THE PURPOSE OF: Ο Adjunctive/Concurrent Care Ο Transfer of Care Ο Other:_____________

I understand that unless revoked, this authorization is valid for 90 days from the date of signing. I understand that

I may revoke this authorization in writing at any time except to the extent disclosure has already been made in accordance with this document. Unless specifically excluded, this authorization includes release of specially protected information requiring my explicit authorization for release. This includes referral, diagnosis, and treatment information related to: (check the accompanying box(es) below to EXCLUDE the information from authorization)

Ο Substance abuse Ο Mental health conditions/Psychotherapy Ο Sexually transmitted infections and


I understand that my healthcare information is protected by state and federal regulations that protect the confidentiality of this information and that my healthcare information may not be released or disclosed without my written authorization, unless otherwise provided by law. I also understand that I do not have to sign this form as a condition for receiving treatment and that I am entitled to a copy of this authorization form at the time of signing. I understand that if I request records for personal use, to hand-carry to another health provider, or for parties not involved in my healthcare, there may be a charge. ‘Non-emergency’ release of records may take up to 15 working days. Emergency requests will be given priority processing. ‘Emergency’ status applies only to release of records directly to another healthcare provider for urgent patient care. There is no charge to release records to another healthcare provider.

Patient’s Signature:_______________________________________________ Date:_________________

Rep./Guardian’s Signature:_________________________________________ Date:_________________

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