• Request for Authorization for Disclosure of Health Information

    Clarinda Regional Health Center

  • Patient Information:

  • DOB *
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Release Information From:

  • Format: (000) 000-0000.

  • Release Information To:

  • Format: (000) 000-0000.
  • Purpose for release of records:*
  • Information to be released:*
  • Mental Health Records to be Released*

  • Date of Service:
    Pick a Date   to  Pick a Date            

  • Is there a second person you would like to grant permission to pick up your medical records?*

  • I AUTHORIZE RELEASE OF ALL ALCOHOL AND/OR DRUG TREATMENT RECORDS THAT ARE PART OF THE RECORDS I SPECIFIED ABOVE UNLESS OTHERWISE INDICATED BELOW:

  • I may revoke this authorization at any time by sending written notice to the facility/provider releasing records. A revocation is not valid if (1) action was previously taken in reliance on this authorization, or (2) If this authorization was obtained as a condition for obtaining insurance coverage. I authorize the facility/provider to disclose medical information to the party identified in the “Release Information To” section. I understand this may include information regarding mental health, alcohol/drug use, and HIV treatment. I understand that once disclosed, information may be re-disclosed by the recipient and no longer protected. I understand this authorization is voluntary and that I may refuse to sign. Unless allowed by law, my refusal to sign will not affect my ability to obtain treatment, receive payment, or my eligibility for benefits.

  • This authorization expires one year from the date of my signature unless I specify a different event, purpose or alternative expiration date here:   Pick a Date   

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Did you sign as a Authorized Representative?*
  • Date of Completion*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: