Your browser does not support JavaScript!
This form cannot automatically check that you have submitted all of the required fields without JavaScript.
Please be sure to submit all required fields (marked with stars).

East Adams Rural Healthcare

Authorization For Release of Medical Information

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.
* Patient's Name
  Date of Birth
  Address
* Phone Number
* I authorize East Adams Rural Healthcare to release information to:
  Name/Facility or Provider
  Address
  City, State, Zip Code
  (Area Code) Phone Number
* I authorize the following to release information to East Adams Rural Healthcare:
  Name/Facility or Provider
  Address
  City, State, Zip Code
  (Area Code) Phone Number
  (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
You may use or disclose the following health care information continued
  Healthcare information in my medical record relating to the following treatment or condition:
  Healthcare information in my medical record for the date(s):
  Other (e.g., x-ray, labs, bills), specific
You may use or disclose the following health care information regarding testing, diagnosis, and treatment for: (initial all that you wish to be disclosed)
  HIV/AIDS
  Sexually Transmitted Diseases
  Psychiatric disorders
  Drug/Alcohol use
  Reason(s) for this authorization: (check all that apply) At my request
Other
  If other please explain
  This authorization ends: (check one) In 90 days from the date signed
On (date)
  If you selected DATE above please specify the date
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.
  Patient or Legal Representative Signature
  Date:
  Relationship to Patient:
  Witness Signature
  Date: