Valley Medical Center of Pennsburg, LLC
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Referrals and Prescriptions
Records Release Request
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Indicates required field
Patient Name
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First
Last
Patient Address
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Patient Phone Number
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Birthdate (MM/DD/YYYY)
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Patient Email
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Description of what is to be disclosed:
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Entire Medical Record
Partial Medical Record
Lab Results
Prescription Record
Auto Injury
Clinical Notes
X-Ray Reports
Worker's Comp
Referral Record
Immunization Record
Physical Examination
This information may be disclosed to and used by the following indiviual or organization: NAME & ADDRESS
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Purpose of disclosure:
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My Personal Records (Charge not to exceed state minimum)
Change in Doctor's Office / Primary Care
Sharing with Healthcare Providers as Needed
At the Request of my Attorney
Other
If "For Attorney" selected, please state Attorney's name and address. If "Other" selected above, please describe.
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This authorization will expire six months from the date of signature unless you request an earlier date or event below.
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I understand that the information to be disclosed may include information relating to AIDS or HIV.
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No
Yes
I understand that the information to be disclosed may include information relating to psychiatric or other mental health treatment.
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No
Yes
I understand that the information to be disclosed may include information about treatment for drug, alcohol or substance abuse.
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No
Yes
By Clicking on the "Submit" Button I am stating that:
I hereby authorize the use or disclosure of the stated individual's health information as described above.
I have read and understand this authorization and authorize the use and/or disclosure of the protected health information as described in this authorization.
I understand that:
- This authorization is strictly voluntary and I may refuse to sign it (or submit it) if I so choose.
- My refusal to submit this authorization will not affect my ability to obtain treatment, except when health services are solely for the purpose of reporting to a third party.
- I may revoke this authorization at any time in writing, but if I do, it will not apply to any disclosure already made in response to this authorization. The revocation will not apply to my insurance company when the law provides my insurer with rights to contest a claim under my policy.
- Once the information listed above has been disclosed, it may be re-disclosed by the recipient and the information may not be protected by Federal privacy laws or regulations.
- I may see and obtain a copy of the information described on this form for a reasonable copy fee.
Name of Person Submitting Form
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First
Last
Relation to Patient
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Submit