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Ninth Street Internal Medicine- AUTHORIZATION FOR RELEASE OF

Ninth Street Internal Medicine- AUTHORIZATION FOR RELEASE OF 2026

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The document is an authorization form from Ninth Street Internal Medicine allowing a patient to release their medical information to a specified individual or entity. It includes sections for the patient's personal details, the types of medical records to be released, the purpose of disclosure, and the patient's rights regarding the authorization. The authorization is valid for 12 months and can be canceled with written notification.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the patient's full name in the designated field at the top of the form.
Fill in the street address, city, state, and zip code of the patient in the respective fields.
Provide the patient's birth date and home phone number in the specified sections.
In the authorization section, write your name as the patient authorizing this release.
Enter the name and address of the company, agency, facility, or person to whom you are authorizing information release.
Select which medical records you wish to be released by checking appropriate boxes for history & physical, laboratory reports, etc.
Indicate the purpose of disclosure by selecting from options like change of doctor or coordination of primary care.
Sign and date at the bottom of the form to complete your authorization.

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Versions	Form popularity	Fillable & printable
2018	4.4 Satisfied (41 Votes)
2011	4.8 Satisfied (58 Votes)

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How to fill out an authorization letter?

How do I write a simple letter of authorization? Start with your name and contact information at the top. Include the current date. Write the recipients name and contact information. Clearly state your name and that youre writing to grant authorization to another individual or organization.

How to fill out an authorization for release of medical information?

Begin by specifying your name, the entity authorized to disclose information, and the individuals or entities you authorize to receive it. Indicate the specific information and purpose for which it will be disclosed, add an expiration date or event, and sign and date the form to confirm your consent.

How do I give permission to share medical information?

Explicit consent It can be given in writing, verbally or through another form of communication, such as sign language.

How do you write an authorization letter for medical records release?

I, the undersigned, authorize the release of, or request access to the information specified below from the medical record(s) of the above name patient. I understand that my records are confidential and cannot be disclosed without my written authorization, except when otherwise permitted by law.