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Authorization to Obtain/Release Medical Records

Authorization to Obtain/Release Medical Records

Patient Name*
Date of Birth*
Date Format: 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
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
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
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*
Date Format: MM slash DD slash YYYY

Mission

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

Vision

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

North Canyon Medical Center
267 N. Canyon Drive
Gooding, ID 83330
(208) 934-4433

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