KAMM, MCKENZIE OB/GYN

OBSTETRICS • GYNECOLOGY • INFERTILITY
3805 Computer Drive Raleigh, NC 27609
Phone 919-781-6200
Fax 919-783-1819


Authorization for Release of Information

PATIENT NAME:

I hereby authorize:

(Print name of provider)

to release information from my medical record as indicated below to:

 

Information to be released

I specifically authorize the release of information relating to:

SIGNATURE OF PATIENT OR LEGAL GUARDIAN

 Purpose of disclosure

 
 
 
 
 
 
 
 
 
1. I understand that this authorization will expire on 
or (60) days after I have signed the form.

2. I understand that I may revoke this authorization at any time by notifying the providing organization in writing, and my revocation will be effective on the date notified except to the extent action has already been taken in reliance upon it.

3. I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by Federal privacy regulations.

4. I understand that by authorizing this release of information;
  • My health care and payment for my health care will not be affected.
  • I understand I may see and copy the information described on this form if I ask for it, and that if desired, I may get a copy of this form after I sign it.
  • I have been informed that  (Print Name of Provider)  /  receive financial or in-kind compensation in exchange for using or disclosing the health information described above.

5. I understand that in compliance with
(Print the State Whose Laws Govern the Provider) statute, I will pay a fee of
 
 SIGNATURE OF PATIENT
PARENT/LEGAL GUARDIAN/AUTHORIZED PERSON

 
 RECORDS RECEIVED BY
 
 

 FOR OFFICE USE ONLY