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East Adams Rural Healthcare
903 S. Adams Ritzville, WA 99169
Phone: (509) 659-1200 Fax: (509) 659-1113 |
Please PRINT form before selecting the SUBMIT button. Also you must have a photo ID with you when you arrive to pick up your medical records. |
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Patient's Name |
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Date of Birth |
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Address |
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Phone Number |
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I authorize East Adams Rural Healthcare to release information to: |
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Name/Facility or Provider |
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Address |
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City, State, Zip Code |
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(Area Code) Phone Number |
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I authorize the following to release information to East Adams Rural Healthcare: |
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Name/Facility or Provider |
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Address |
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City, State, Zip Code |
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(Area Code) Phone Number |
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(I. My Authorization) You may use or disclose the following health care information (Check all that apply) |
Health care information for the following time period 1 yr 2 yr 5 yr All health care information in my medical record
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You may use or disclose the following health care information continued |
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Healthcare information in my medical record relating to the following treatment or condition: |
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Healthcare information in my medical record for the date(s): |
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Other (e.g., x-ray, labs, bills), specific |
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You may use or disclose the following health care information regarding testing, diagnosis, and treatment for: (initial all that you wish to be disclosed) |
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HIV/AIDS |
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Sexually Transmitted Diseases |
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Psychiatric disorders |
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Drug/Alcohol use |
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Reason(s) for this authorization: (check all that apply) |
At my request Other
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If other please explain |
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This authorization ends: (check one) |
In 90 days from the date signed On (date)
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If you selected DATE above please specify the date |
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II. My Rights I understand I do not have to sign this authorization in order to get health care benefits (treatment, payment or enrollment). However, I do have to sign an authorization form: · To take part in a research study; or · To receive health care when the purpose to create health care information for a third party. I may revoke this authorization in writing. If I did, it would not affect any actions already taken by East Adams Rural Hospital based upon this authorization. I may not be able to revoke this authorization if its purpose was to obtain insurance. Two ways to revoke this authorization is to: Fill out a revocation form, available from East Adams Rural Hospital, or to write a letter to East Adams Rural Hospital. Once health care information is disclosed, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it. |
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Patient or Legal Representative Signature |
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Date: |
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Relationship to Patient: |
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Witness Signature |
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Date: |
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