Desert River Solutions

Authorization for Release of Medical Records


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 AIDS (Acquired Immunodeficiency Syndrome) or HIV (Human Immunodeficiency Virus) infection, psychiatric care and/or psychological assessment and treatment for alcohol and/or drug abuse.

 

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.

Please provide Relationship To Patient if You are NOT the Patient 

Leave this empty:

Desert River Solutions https://desertriversolutions.com
Signature Certificate
Document name: Authorization for Release of Medical Records
Unique Document ID: 760fbcfb163167248db8c9bef46945522ff71e2b
TimestampAudit
April 18, 2019 10:24 am MSTAuthorization for Release of Medical Records Uploaded by Andrew Szmuc - [email protected] IP 108.162.215.205, 127.0.0.1
April 18, 2019 10:27 am MSTDesert River Solutions - [email protected] added by Andrew Szmuc - [email protected] as a CC'd Recipient Ip: 172.68.46.218, 127.0.0.1
April 18, 2019 10:35 am MSTDesert River Solutions - [email protected] added by Andrew Szmuc - [email protected] as a CC'd Recipient Ip: 172.68.46.218, 127.0.0.1
April 18, 2019 11:23 am MSTDesert River Solutions - [email protected] added by Andrew Szmuc - [email protected] as a CC'd Recipient Ip: 108.162.215.145, 127.0.0.1
April 19, 2019 9:27 am MSTDesert River Solutions - [email protected] added by Andrew Szmuc - [email protected] as a CC'd Recipient Ip: 108.162.215.205, 127.0.0.1