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Addiction Treatment
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General Surgery
Hand & Wrist
Laboratory
Orthopedics
Pain Management
Pediatrics
Quick Care
Rehabilitation
Respiratory Therapy
Sleep Studies
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Find a Doctor
Addiction Treatment
Anesthesia
Behavioral Health
Cardiology
Dermatology
Emergency Medicine
Family Medicine
Foot & Ankle
General Surgery
Hand & Wrist
Hospitalists
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Quick Care
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Search for:
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
Alabama
Alaska
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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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
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New York
North Carolina
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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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Board of Directors
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Addiction Treatment
Behavioral Health
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Diabetes & Nutrition
Diagnostic Imaging
Emergency Medicine
Family Medicine
Foot & Ankle
General Surgery
Hand & Wrist
Laboratory
Orthopedics
Pain Management
Pediatrics
Quick Care
Rehabilitation
Respiratory Therapy
Sleep Studies
Urology
Find a Doctor
Addiction Treatment
Anesthesia
Behavioral Health
Cardiology
Dermatology
Emergency Medicine
Family Medicine
Foot & Ankle
General Surgery
Hand & Wrist
Hospitalists
Nephrology
Orthopedics
Pain Management
Patient Portal
Pediatrics
Quick Care
Radiologists
Sleep Studies
Urology
Patient Info
Billing & Payments
Financial Assistance
Insurance Plans
Medical Records
Patient Portal
Pay Bill Online
Pricing Transparency
Privacy Rules
Giving Back
Ways To Give
Chapel Construction Project
Auxiliary Thrift Store
Philanthropy Board
Careers
Careers at NCMC
Open Positions
Locations
Buhl Clinic
Jerome Clinic
Medical Center
Specialty Clinic
Twin Falls Clinic
Maps & Directions