Form 074 (Authorization to Release Patient Health Information)



Click here to enter text.2206625-161925AUTHORIZATION TO RELEASE PATIENT HEALTH INFORMATION00AUTHORIZATION TO RELEASE PATIENT HEALTH INFORMATION220345-20002500Patient Name: FORMTEXT ????? Incident No. (If known): FORMTEXT ?????Date of Birth: FORMTEXT ?????I authorize South Kitsap Fire and Rescue (SKFR) to release information as stated below:INFORMATION TO BE RELEASED TO: FORMCHECKBOX Myself:Office Use Only: FORMCHECKBOX ID Verified by SKFR Staff FORMCHECKBOX Other Name (Organization/Person): FORMTEXT ????? Street Address: FORMTEXT ????? City, State, Zip: FORMTEXT ?????Phone: FORMTEXT ?????Email: FORMTEXT ?????INFORMATION TO BE RELEASED:Location where service was provided (address or cross-street): FORMTEXT ?????Date of Service: FORMTEXT ????? Time (if known): FORMTEXT ?????Information Requested: FORMCHECKBOX Incident Report FORMCHECKBOX Medical Report FORMCHECKBOX Billing What is the purpose of this disclosure? FORMTEXT ????? How would you like to receive the document? (See fee schedule) FORMCHECKBOX Electronic (requires email address above) FORMCHECKBOX Pick up in person FORMCHECKBOX MailAUTHORIZATION FOR RELEASE OF INFORMATION:I UNDERSTAND THAT authorizing the disclosure of this healthcare information is voluntary. I can cancel this authorization at any time by writing to SKFR. I understand that once the information has been released according to the terms of this authorization, the information cannot be recalled. Any disclosure of information carries with it the potential for further release or distribution by the recipient that may not be protected by confidentiality laws. This authorization will expire 90 days from the date signed below unless another date or event is entered here FORMTEXT ?????____. SIGNATURE OF PATIENT / LEGAL REPRESENTATIVE: Signature of Patient or Legal Representative (Circle one) : Date (month/day/year) : FORMTEXT ????? If not signed by Patient: Print name and relationship to patient and description of Authority FORMTEXT ?????Requesting Medical Records on Behalf of Another Person: If you are requesting medical records for someone other than yourself, you may be required to provide additional documentation to show that you have a legal right to request the record set. Examples of these documents include Power of Attorney, Letters of Representation, Guardianship Papers, etc.Send completed form and any attachments to PublicRecordRequest@ or mail to:South Kitsap Fire and Rescue 1974 Fircrest DR SE Port Orchard, WA 98366 ................
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