Wimahl Family Clinic - Publicforms

Available Forms

RELEASE OF INFORMATION Consent Form - Adult Portal Consent Form

RELEASE OF INFORMATION

WIMAHL FAMILY CLINIC, INC.

PATIENT AUTHORIZATION TO DISCLOSE PERSONAL HEALTH INFORMATION

Patient Name (First, Middle, Last) *

Address *

City, State, Zip *

Date of Birth (mm/dd/yyyy) *

WIMAHL FAMILY CLINIC is authorized to *

Recipient/Discloser *

Address *

Phone/Fax *

BY CHECKING THE BOX, I AUTHORIZE RELEASE OF THE FOLLOWING MEDICAL RECORDS:

I GIVE PERMISSION TO RELEASE ALL MY MEDICAL RECORDS including information and records or copies of records relating to the history, diagnosis, treatment or services rendered to me in connection with any condition or disease. This includes permission to release POTENTIALLY SENSITIVE INFORMATION which may include information concerning my treatment of mental illness, Human Immunodeficiency Virus (HIV), alcoholism, drug use/dependency, venereal disease, sexual assaults, abortion, illegitimacy of birth, communications to social workers and/or psychotherapies, psychologists, if any.

I GIVE PERMISSION TO RELEASE ONLY RECORDS specifically described below

Please list specific records being requested

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I release Wimahl Family Clinic, Inc., and the Recipient/Discloser listed above, and any of their providers and staff from all responsibility or liability that may arise from this authorization. I may withdraw this authorization at any time by giving written notification to Wimahl Family Clinic, Inc., provided that I do so in writing and to the extent that you have already disclosed the information in reliance on this authorization.

This Authorization expires on

(Optional) If no expiration date is given, then this authorization shall remain in effect for a period reasonably needed to complete the request.

Patient Signature (Parent's Representative, if minor)

(name typed here is equivalent to a signature)

Date

* Required field