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):
Email Address On Where to Send To (CANNOT be Hotmail accounts):
I DO I DO NOT
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:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Authorization for Release of Medical Records
Agree & Sign