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AUTHORIZATION FOR DISCLOSURE OF MEDICAL RECORDS SAN JUAN HEALTH PARTNERS Cardiology Aztec Patient ID Verified: Y Bloomfield General Surgery Verified by: __________________ Internal Medicine and Pulmonology Urgent Care Date: _______________________ Midwifery and Women’s Health N MR Number: ________________ Neurology and Neurosurgery Pediatrics To maintain confidentiality, the patient or legal representative must complete bold items, sign this form and present a picture ID I hereby authorize you to disclose the following information from the medical records of: Patient Name: _______________________________________________________________________________________________ Date of Birth: _____________________________________________ SSN: _____________________________________________ Address: _________________________________________City: ____________________________ State: ______ Zip: ___________ Telephone: ___________________________ Time period of requested information: _____________________________________ THIS INFORMATION IS TO BE DISCLOSED To: _______________________________________ Address: ___________________________ _____________________________ City: _____________________________________ State: ____________ Zip: __________ Telephone: _______________________ THIS INFORMATION IS TO BE DISCLOSED From: ___________________________________________ Address: __________________________________________________ City: _____________________________________ State: _____________ Zip: __________ Telephone: ______________________ You have the right to restrict information. The information below will not be disclosed unless you check the box. Progress Notes Lab Results/Reports EKG/ECG RX Records Correspondence Radiology Reports Billing, Invoices and Statements Previous Physician Records Other: __________________ HIV/AIDS Related Information Psychological/Psychiatric Evaluation Drug/Alcohol Related Information REQUIRES ADDITIONAL SIGNATURE TO DISCLOSE _____________________________________________ PURPOSE FOR DISCLOSURE At request of individual For the following purposes _________________________________________________________________________________________________________________ _______________________________________________________________________________________________________ It is further understood that the information disclosed is for the purpose stated above and may not be provided in whole or in part to any other agency, organization or person. This information has been disclosed to you from records whose confidentiality is protected by State Law. The State Law prohibits you from making further disclosure of such information without specific written consent of the person to whom the information pertains or is otherwise permitted by State Law. ___________________________________________ Signature of patient or legal representative ___________________________________________ Date ________________________________________________ ___________________________________________ Relationship to Patient Witnessed by This consent will expire one year after date of signature. You have the right to revoke this authorization at any time.