Download PATIENT INFORMATION - Welsh Mountain Health Centers

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