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____ Pages documenting the diagnosis of: ________________ ___________________________________________________ ____ All hospital records ( incl. Nursing records and progress) ____ Transcribed hospital reports ____ Medical records needed for continuity of care ____ Most recent TWO year history ____ Emergency and urgency care records ____ Billing statements ____ Entire medical record (all information) ____ Genetic testing information |
____ Pages documenting the diagnosis of: ________________ ___________________________________________________ ____ Pathology reports ____ Dental records ____ Physical therapy records ____ Laboratory reports ____ AIDS or HIV information ____ Clinician office chart notes ____ Drug and Alcohol Information ____ Other ______________________________________ |
| If we are requesting this Authorization from you for our own use and disclosure or to allow another health care provider or health plan to disclose information to us: 1. We cannot condition our provision or services or treatment to you on the receipt of this signed authorization; 2. You may inspect a copy of the protected health information to be used or disclosed; 3. You may refuse to sign this Authorization; and 4. We must provide you with a copy of the signed authorization. You have the right to revoke this Authorization at any time, provided that you do so in writing and except to the extent that we have already used or disclosed the information in reliance on this Authorization. Unless revoked earlier or otherwise indicated, this Authorization will expire 180 days from the date of signing or shall remain in effect for the period reasonable needed to complete the request. |