mime-version: 1.0 content-location: file:///C:/28672350/Pt.RecordReleaseFormTOUs-wp.htm content-transfer-encoding: quoted-printable content-type: text/html; charset="us-ascii" WILLIAM L

Authorization = for Release of Patient Information

 

 

Patient’s Name:________________________________        = ;            Date:____= _______________

Address:______________________________________        =            Date of Birth:____________

 __________________________________= ____

 

 

I hereby authorize the release of my clinical information:

 

FROM THE OFFICE OF:     &nb= sp; ______________________________________________________

Address: &= nbsp;         _____________= _________________________________________

  &nb= sp;            = ;         _________________= _____________________________________

Phone: ______________= _______  FAX:_= ____________________

 

TO THE OFFICE OF:             Drs. Cowley & Gudas

        =             &n= bsp;           &nbs= p;            =    633 E. 13th St., P.O. Box = 365

Wi= namac, IN   46996

        =             &n= bsp;           &nbs= p;            =    Phone:  574-946-3944      =       FAX:  574-946-6843

 

I authorize the release of my personal health care information, including (w= hen applicable) information on

substance abuse, AIDS or HIV infection, and mental health information.  I understand that I can revoke

this authorization, in writing, at any time by sending the appropriate notification.  The only excep= tion to the

right to revoke is if action has already been taken based upon this ori= ginal authorization.  I understand = that

I have a right to inspect or copy health information used or disclosed as al= lowed by Federal law.  I

understand that information used or disclosed pursuant to this authorization could be subject to disclosure

by the recipient.  I understand = it is my  decision to sign this authorization, and that treatment cannot be

refused if I do not sign this form.  I understand that there may charges allowed by law for photocopying=

large records, especially when complete records are requested.  I hereby authorize the release or exchange

of information regarding my visual examination and history and do further specifically release the forwarder

in regard to the transmittal of such visual information.

 

 

 

_______________________________________________        = ;      _______________________

Signature of Patient or Responsible Party        =             &n= bsp;           &nbs= p;            = Date Signed

 

 

A parental signature is required for un-emancipated minors (under age 18).  When a patient is deceased <= /o:p>

or physically or mentally impaired, the appropriate legally designated representative of the patient may sign.&n= bsp;

This includes the legal guardian or power of attorney.