Authorization for Other Healthcare Provider to Release Medical Information to Southern Cancer Center Patient's Name Last First Middle Maiden Name First Patient's DOB - must be mm/dd/yyyy format MM slash DD slash YYYY Previous AddressCurrent addressI hereby authorize and request release of records by:Name First Name First Untitled Untitled Untitled Untitled PhonePhoneTo release to Southern Cancer Center:Name First Name First Untitled Untitled Untitled Untitled PhonePhoneA copy of the medical records of the above-named patient pertaining to: (Check appropriate box and list the date)Checklist 1 Emergency Care Hospitalization Outpatient Care Date 1 - must be mm/dd/yyyy format MM slash DD slash YYYY From - must be mm/dd/yyyy format MM slash DD slash YYYY to - must be mm/dd/yyyy format MM slash DD slash YYYY Date 3 - must be mm/dd/yyyy format MM slash DD slash YYYY Check appropriate box (s) as needed:Untitled History and Physical Discharge Summary Operative Report Occupational Therapy Notes Physical Therapy Notes Lab Pathology X-Ray Abstract (H&P, discharge summary, consult, OP report) Other REQUIRED The purpose of the request for the Medical Record is:Untitled(Required) at the request of the patient for diagnosis/treatment purposes Other (explain) REQUIREDUntitled(Required) I do I do not Authorize the release of information, including, if applicable, specific laboratory tests of HIV Infection (Human Immunodeficiency Virus, the causative agent of AIDS) or the diagnosis of Acquired Immune Deficiency Syndrome (AIDS) or AIDS related conditions, all medical records or other information regarding my treatment, hospitalization including psychological or psychiatric impairment, drug abuse and/or alcoholism or sickle cell anemia.Releasor, its agents and employees, are hereby authorized to obtain, inspect, and reproduce such records and/or information and are hereby relieved of any responsibility or liability that may arise from the release or reproduction of such records and/or information in accordance with this Authorization. This Authorization will expire one (1) year from the date of my signature. I understand that I have the right to revoke this Authorization, if the revocation is in writing except if (i) Releasor has taken action in reliance upon this Authorization, or (ii) if this Authorization was given as a condition of obtaining insurance coverage, other law provides that the insurance company has the right to contest a claim under the insurance policy. I understand that I may revoke this Authorization by providing a written revocation to the provider from which records are requested in the box above. I understand that my Protected Health Information that is used or disclosed under this Authorization may be subject to redisclosure by the recipient, and the privacy of my Protected Health Information may no longer be protected by law. Patient SignaturePatient Signature Date - must be mm/dd/yyyy format MM slash DD slash YYYY Authorized Representative if Patient unable to sign:Authorized Representative if Patient unable to sign: Date - must be mm/dd/yyyy format MM slash DD slash YYYY Description of Authorized Representative’s Authority to Sign for PatientDescription of Authorized Representative’s Authority to Sign for Patient Date - must be mm/dd/yyyy format MM slash DD slash YYYY
