Release of Information to John R. Knudsen, MD
PO Box 1582 Ferndale, WA 98248, Phone: 360-483-5260
Fax to: 360-483-5264
Patient Information
Patient name
Patient birthdate
Patient address
Information to be released from:
Information to be released
Purpose for disclosure
Patient authorization
I understand that my records may contain information regarding the diagnosis or treatment of HIV/AIDS, sexually transmitted diseases, drug and/or alcohol abuse, mental illness, or psychiatric treatment. I give my specific authorization for these records to be released.
My rights
I understand I do not have to sign this authorization in order to obtain health care benefits (treatment, payment or enrollment). I may revoke this authorization in writing. If I did I would not affect any action already taken by John R Knudsen, MD based upon this authorization. I may not be able to revoke this authorization if its purpose was to obtain insurance. I may revoke this authorization in writing to John R Knudsen, MD. Once health care information is disclosed, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it.
