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Authorization to Obtain/Release Medical Records

Authorization to Obtain/Release Medical Records

Patient Name*
Date of Birth*
MM slash DD slash YYYY
Phone*
Email*
Address*
Street Address City State ZIP Code
This is to authorize the described medical records to the the above patient...
ARE YOU REQUESTING RECORDS TO BE SENT TO OR FROM NORTH CANYON MEDICAL CENTER?*
- TO: NORTH CANYON MEDICAL CENTER
- FROM: NORTH CANYON MEDICAL CENTER
How would you like your records to be sent?*
- Patient to pick up at North Canyon in Gooding
- Papercopy via Mail
- Fax
- E-mail
Fax number to send your records:*
Please enter where you would like the records to be released from:
Facility / Provider / Individual*
Address*
Street Address City State ZIP Code
Phone*
Fax
Records Requested (check all that apply)
*
- All Records
- Consultations
- Lab Reports
- Emergency Care
- History & Physical
- Radiology
- Urgent Care Notes
- Discharge Summary
- Other
Date(s) of Service: *
From:*
From:
MM slash DD slash YYYY
To:*
To:
MM slash DD slash YYYY
Please enter where you would like the records to be released to:
Facility / Provider / Individual*
Address*
Street Address City State ZIP Code
Phone*
Fax
Records Requested (check all that apply)
*
- All Records
- Consultations
- Lab Reports
- Emergency Care
- History & Physical
- Radiology
- Urgent Care Notes
- Discharge Summary
- Other
The following types of records require specific authorization: Each type must be initialed below for the request to be valid.
Psychiatric Notes
Initial To Authorize
Drug Addiction Treatment
Initial To Authorize
HIV Treatment
Initial To Authorize
Patient Photo or Driver's License Upload
Accepted file types: jpg, gif, png, pdf, Max. file size: 20 MB.
This authorization is valid for 90 days from the date signed unless a different date or event is specified here:
Patient Signature*
THIS AUTHORIZATION MAY BE REVOKED AT ANYTIME IN WRITING. TO REVOKE, THE PATIENT MUST SUBMIT A LETTER REQUESTING THE AUTHORIZATION BE REVOKED TO THE DIRECTOR OF HEALTH INFORMATION. RELEASING YOUR MEDICAL INFORMATION AS A RESULT OF THIS AUTHORIZATION MAY MEAN THAT YOUR MEDICAL INFORMATION COULD BE RERELEASED BY THE RECIPIENT AND NO LONGER BE PROTECTED BY FEDERAL PRIVACY RULES.
Date*
MM slash DD slash YYYY

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Powered by excellence, we are growing a medical organization that serves our communities.

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We aspire to be your first choice for healthcare through an expanded network of medical services of the highest quality.

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North Canyon Medical Center

Copyright © 2021 North Canyon Medical Center
267 N Canyon Dr, Gooding, ID 83330
(208) 934-4433 • info@northcanyon.org

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About
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