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AUTHORIZATION FOR RELEASE OF RECORDS PATIENT INFORMATION PATIENT NAME DATE OF BIRTH STREET ADDRESS APARTMENT NUMBER CITY STATE ZIP CODE PHONE DISCLOSED INFORMATION Check all information to be released. PSYCHIATRIC RECORD Yes, Enclose No, Do Not Enclose DENTAL RECORD Complete Record Pertinent Treatment Information X-Rays Other _________________________________________ MEDICAL RECORD Complete Record Pertinent Treatment Information Labs And Imaging Other _________________________________________ DRUG/ALCOHOL ABUSE TREATMENT INFORMATION Yes, Enclose No, Do Not Enclose AIDS/HIV INFORMATION Yes, Enclose No, Do Not Enclose INFORMATION RELEASED FROM This section must be filled out completely in order for your records to be received from the correct location. Thank you. FACILITY NAME STREET ADDRESS SUITE CITY STATE OFFICE PHONE ZIP CODE OFFICE FAX INFORMATION PROVIDED TO (CHECK ONE) Welsh Mountain Meadow Creek Lebanon Ridge Lebanon Ridge Medical & Dental Center Family Practice Community Health Oral Health 584 Springville Road 435 S. Kinzer Avenue, Suite D 840 Norman Drive 101 S. 9th Street New Holland, PA 17557 New Holland, PA 17557 Lebanon, PA 17042 Lebanon, PA 17042 PHONE FAX PHONE FAX PHONE FAX PHONE FAX 717-354-4711 717-355-0259 717-351-2400 717-351-2407 717-272-2700 717-272-2757 717-450-7015 717-273-2817 EMAIL EMAIL EMAIL EMAIL [email protected] [email protected] [email protected] [email protected] PURPOSE OF DISCLOSURE AUTHORIZATION EXPIRES Changing to a Welsh Mountain Health Centers’ practice 1 year from below date Personal use Other __________________________________________________ Other __________________________________________ If not noted, authorization expires 6 months from the date below. AUTHORIZATION I hereby authorize Welsh Mountain Health Centers to receive the health information disclosed above. Patients 14 years of age or older and treated for mental illness or drug/alcohol abuse must sign this authorization themselves. Welsh Mountain Health Centers may not condition treatment on my agreement to sign this authorization. I understand that I may revoke this authorization at any time. I understand that to revoke this authorization, I must do so in writing. I understand that the revocation will not apply to information that has already been released. X RELATIONSHIP TO PATIENT: Patient (Self) Parent Date: Guardian Legal Representative Power of Attorney Other ______________________ Welsh Mountain Medical & Dental Center Meadow Creek Family Practice Lebanon Ridge Community Health Lebanon Ridge Oral Health 6/8/16