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 (CANNOT be Hotmail accounts):

 

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:

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Signature Certificate
Document name: Authorization for Release of Medical Records
lock iconUnique Document ID: 37173c539ff397156878e2e26099c555a6b0f182
Timestamp Audit
March 3, 2021 2:04 pm MSTAuthorization for Release of Medical Records Uploaded by Andrew Szmuc - [email protected] IP 172.68.189.238