Authorization For Release Of Information

Fill in information on Last Hospitalization

authorization-for-release-of-information-last-hospitalization

Independence Center - Authorization for Release of Information

(Required)
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REQUEST/AUTHORIZE Independence Center Health Group to RELEASE/OBTAIN all information concerning my medical, psychiatric, alcohol & drug abuse, AIDS/HIV and other communicable diseases, test results and/or diagnosis and treatment records.

MAILING ADDRESS

TO/FROM:

Independence Center Health Group
4219 Laclede Ave. (Rear)
St. Louis, MO 63108
Phone: 314.286.4545
Fax: 314.286.4542

Street Address

I am requesting that records for the following time period be released:

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I am requesting that the specific information noted below be released/obtained:(Required)
I am requesting this information to be released/obtained for the following purpose(s):(Required)

PLEASE USE CAUTION - READ BEFORE SIGNING

ATTENTION: Once this information has been released pursuant to this Authorization, it may no longer be protected by Federal and/or State law/regulations and may no longer be deemed “Confidential”.

I state that I have read and fully understand the above “Authorization for Release of Information” and I specifically request its release for the above-mentioned purpose, and to be furnished to Independence Center or to whom I have authorized. I further state that I have executed this Authorization as my one free act and deed. I agree that I have received a signed copy of this Authorization if I chose to do it.

I understand that I may revoke this Authorization at any time except to the extent that prior action has been taken in reliance on this Authorization. This Authorization will expire after one year from the my signature and date below, if I do not cancel it in writing prior to the expiration date. I understand that if I want to cancel/revoke this Authorization, I must mail, fax or bring a letter in person stating that I want to cancel this authorization. I understand that I need to mail, fax or bring the letter to the address or fax number listed above.

If you are signing on behalf of an individual for whom you are the legal guardian or personal representative, you must attach a certified copy of your appointment as legal guardian or personal representative. If you are signing on behalf of an individual who is deceased, you must attach a certified copy of the patient’s death certificate.

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