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Medical Records Release to Diamond

Authorization For Release Of Medical Information

Authorization For Release Of Medical Information

"*" indicates required fields

Patient Name*
Previous Name(s)
MM slash DD slash YYYY
Date of Birth:

Where are you releasing your records FROM?
Address*

Where are you releasing your records TO?
Diamond Womens Center

Types Of Records*
Reason For Request*
(please record the purpose of the disclosure or check patient request):

I Understand That By Signing The Below:

  • I may revoke this authorization at any time by notifying i-Health in writing. If I revoke this authorization, i-Health will no longer use or disclose my health information for the reasons covered by this authorization, except to the extent it has already relied upon this authorization.
  • By authorizing the release of my protected health information, the health information may no longer be protected and has the potential to be re-disclosed.
  • There may be a fee for release of this information and I may be responsible for that fee.
  • I am authorizing the release of my personal protected health information from any i-Health facility, unless otherwise specified above.
  • Treatment will not be denied to me if I do not sign this form.
  • If I provided an email address in section 3, I understand that the requested records will be sent via encrypted email, or it may be sent to a patient portal.
  • i-Health is a multispecialty practice including, and without limitation, the clinic above. Your i-Health record will be released, unless you otherwise specify in writing
Signed By
MM slash DD slash YYYY
Date
Clear Signature
Print Name
MM slash DD slash YYYY
Date

*If this form is signed by someone other than the patient, legal documentation showing guardianship or authorization must be on file or presented with this form

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Phone: 952-927-4045
Fax: 952-927-0867​
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