Anchor Medical Group

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

Patient Name * Date of Birth * Patient Address * Patient Phone Number *

I AUTHORIZE THE RELEASE OF MY RECORDS FROM: Anchor Medical Group

2841 Debarr Road, Suite 24, Anchorage, AK 99508

Phone: (907)279-4953

Fax: (907)334-9667

TO: Independence Park Medical Services

9500 Independence Drive, Ste 900

Anchorage, AK 99507

Phone: 907-522-1341

Delivery Method * Information to Disclose * Purpose of Information * If Other, please describe

I acknowledge that information to be released MAY INCLUDE material that is protected by law. My initials and my signature below authorize release of the following type of information to the extent permitted by law:

Drug or Alcohol Abuse * Mental Health * HIV Information *

I understand that this disclosure of health information is voluntary. I can refuse to sign this authorization. I do not need to sign this release in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in 45 CFR 165.524. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and may no longer be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the Privacy Officer at Anchor Medical Group. This consent is subject to revocation at any time except to the extent that the department has already taken action on it. If not previously revoked, this consent will terminate on the date selected below, or not to exceed 90 days from the date signed.

Termination date if earlier than 90 days Today's Date *

Signature: I have read this authorization, I have had the opportunity to ask questions, I understand the authorization, and I am freely signing this authorization.

Patient Signature *