Authorization of Release of Records Moss


 

Your Full Address:

Requesting From (Old Name of Doctor or Medical Office):

 

I authorize Desert River Solutions to SEND medical records TO THE FOLLOWING and by the FOLLOWING OPTION:

**Please choose ONLY ONE of the options**

Send To (Name):

Address:

Email Address On Where to Send To:

 

authorize the release of information related to HIV Test Results.

authorize the release of information related to Substance Abuse Treatment Information.

authorize the release of information related to Mental Health Information.

 

I authorize the release of an electronic version of my medical records in the possession or control of the above named provider/clinic/hospital; its employees and agents. I acknowledge that this authorization expires in one (1) year unless a different date is specified.

Please provide Relationship To Patient if You are NOT the Patient:

Leave this empty:

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Signature Certificate
Document name: Authorization of Release of Records Moss
lock iconUnique Document ID: 4d5865112dec57fa99e262e7c245a111c3c86e78
Timestamp Audit
December 31, 2021 8:30 am MSTAuthorization of Release of Records Moss Uploaded by Andrew Szmuc - [email protected] IP 70.166.116.246