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Patient
Name: Print the name, address and daytime telephone
number of the patient whose records are being disclosed.
Only one patient per form.
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Date of
Birth: Enter month, day and year of patient’s birth.
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I hereby
authorize _____________: This can be a name of any
health care provider or facility who has the records to be
released ( i.e. Dr. Jones or ADC. If only one Doctor name is
listed then only that provider’s information will be
released.) If information is being requested from another
health care provider outside of ADC and you would like this
information to be sent to ADC, then include complete mailing
address and mail request to that provider. ADC does not mail
the form.
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Date of
Services: Time frame of selected information to be
released. Can be one day or a range of dates or years. If no
time frame is given, then the most recent two years of
information will be released.
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Description of Information to be released:
This is to guide us to select the proper documents to
fulfill the request.
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Select
types of information to be released: Select all that
apply. If your ADC record contains information from another
provider, please check the other box and write “outside
records” and the name of the facility. Please understand
that we will only have copies and they may not be complete.
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This
information may be disclosed to and used by the following
organization (the destination of the records): Enter
the complete name of person/physician/facility/company,
along with the mailing address to receive the information, a
telephone number is helpful. If records are needed by more
than one person/facility, a separate request is required. If
records are for yourself, please write your complete name
and address. Include a contact telephone number.
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Description of the purpose of the use and/or disclosure:
Reason for the request. Check all that apply.
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Expiration Date: Please enter an expiration date or
event. If left blank, the authorization will automatically
expire in 180 days. Do not use “indefinite”.
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Signature
of Patient or Patient Representative: the patient or
representative must sign the form.
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Date:
Enter in date authorization is signed.
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Printed
Name of Patient or Patient Representative: this is
for verification purposes.
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Relationship to Patient: If you are a patient
representative, please indicate your relationship to the
patient. Except in the case of parents, we require a copy of
the documentation appointing you as person with authorized
access.
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Legal
Authority: Legal guardian etc. We require a copy of
the documentation appointing you as person with authorized
access.
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