AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
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
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:
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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.
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.
By typing my name above, I certify that this represents my Electronic Signature.