Authorization for Release of Medical Information

PATIENT name

First Name

Middle Name

Last Name

Previous name, if different

First Name

Middle Name

Last Name

Date of Birth

______________________________

Send my records FROM:

If you are requesting records from the Mayo clinic to be sent to our clinic we will need your Mayo MRN number in order for them to process.

MRN Number

Clinic Address

City

State

Zip/Postal code

Country

Provider Name

Clinic Phone

Clinic fax number

______________________________

Send my records TO:

email: info@helloalmara.com

Types of records

Please choose the type of records you want sent. If you choose something other than All Records, you can choose multiple options.

I Understand That By Signing The Below:

I may revoke this authorization at any time by notifying i-Health in writing. If I revoke this authorization, i-Health will no longer use or disclose my health information for the reasons covered by this authorization, except to the extent it has already relied upon this authorization.
By authorizing the release of my protected health information, the health information may no longer be protected and has the potential to be re-disclosed.
There may be a fee for release of this information and I may be responsible for that fee.
I am authorizing the release of my personal protected health information from any i-Health facility, unless otherwise specified above.
Treatment will not be denied to me if I do not sign this form.
If I provided an email address in section 3, I understand that the requested records will be sent via encrypted email, or it may be sent to a patient portal.
i-Health is a multispecialty practice including, and without limitation, the clinic above. Your i-Health record will be released, unless you otherwise specify in writing

Signed by:

Patient Patient representative

This authorization will expire 1 year from the date I sign this form, Unless specified:

Printed name represents authorized signature acknowledgement

Signature

Date

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

Please fill out the form below. Fields marked with "*" are required fields

PATIENT name

Previous name, if different

Types of records

I Understand That By Signing The Below:

Services

Company

Find a location

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

Please fill out the form below. Fields marked with "*" are required fields

PATIENT name

Previous name, if different

Types of records

I Understand That By Signing The Below:

Services

Company

Find a location

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