Authorization for Release of Protected Health Information

Please complete and submit the electronic authorization below, or you may download, print out and fill in a paper authorization by clicking this link >
Remember to click SUBMIT at the end of the form.

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION TO EVERGREEN PLACE

Name

First Name

Last Name

Email

I give my consent to (doctor’s name):

Who can be reached at FAX #

(###)

###

####

to release the last six months of information from my medical record to: Admissions, Evergreen Place, 813 Beech St. ,Manchester NH 03104 - Phone: 603-669-7361 - Fax: 603-606-5656

I understand that my medical record may contain information relating to drug and/or alcohol abuse, psychiatric history, sexually transmitted infections, social services, HIV (AIDS) testing and treatment records, genetic testing and/or sensitive information. I agree to release all records except as noted below.

Drug/Alcohol Abuse Notes

Sexually Transmitted Disease Notes

HIV (AIDS) Testing and Notes

Psychiatric Notes

Social Services

Genetic Testing

I understand I may revoke this authorization at any time. This authorization will expire on the date below, or in one year if a date is not entered.

MM

DD

YYYY

Patient/Authorized Representative Signature

Your typed name is considered your electronic signature

EVERGREEN PLACE WILL NOT DISCLOSE INORMATION COLLECTED TO ANY SOURCE OTHER THAN WHAT HAS BEEN AUTHORIZED UNDER THE HIPAA PRIVACY ACT. THE INFORMATION COLLECTED WILL BE USED TO DETERMINE CARE NEEDS.