Patient Authorization for Release of Information To have your records released to to obtain your medical or PCHS-Main Office PCHS-Dental Records, you must provide the following information to us for 230 E. Marydale, Soldotna, 395 Main Street Loop Alaska 99669 Kenai, AK 99611 each entity or organization you want records sent to or obtained Phone (907) 262-3119 Phone (907) 283-7759 from. Fax (907) 262-9290 Fax(907) 283-4883 This disclosure is for (choose ONE only): Personal Legal Request Further Medical Care First Name: Last Name: Soc Sec No. XXX-XX- Date of (Choose ONE only) I hereby authorize PCHS to: ____ Get your records from: ~OR~ ____ Release your records to: Name: Address: City: State: Zip Code: Phone: Fax: Please initial the information to be released or obtained: Demographic Information Only Medical Records Behavioral/Mental Health/Integrated Assessment Dental Records Psychological Tests/Reports Lab/X-ray Results Psychiatric Evaluation/Record(s)/Assessment(s) Other (explain): All of my PCHS Health Care Records From date: _____________ To date: _______________ I understand that this request may include diagnoses, consultations, evaluations, Integrated Assessments, Treatment Plans, tests/results, medications, and treatment for all Medical, Behavioral Health, Psychological, Psychiatric, Substance and Alcohol Use and/or Dental records. I understand that federal or state law may restrict re-disclosure of HIV/AIDS, mental health information, genetic testing information, and drug/alcohol diagnosis, treatment, or referral information. If Behavioral/Mental Health/Integrated Assessment, or Psychiatric Evaluation/Records/Assessment are initialed above (marked with please initial the appropriate yellow box below as required by Federal Regulations. “”), disclosed ONLY if I place my initials in the I understand and that the information marked with a above will be “” applicable space below next to the type of information requested: HIV/AIDS testing information/results Mental Health specific visits Substance/Alcohol Use treatment visits/progress Genetic testing
PCHS-Main Office 230 E. Marydale, Soldotna, Alaska 99669 Phone (907) 262-3119 Fax (907) 262-9290 PCHS-Dental 395 Main Street Loop Kenai, AK 99611 Phone (907) 283-7759 Fax(907) 283-4883 Patient Authorization for Release of Information To have your records released to or to obtain your medical Records, you must provide the following information to us for each entity or organization you want records sent to or obtained from. This disclosure is for (choose ONE only): Personal Legal Request Further Medical Care First Name: Last Name: Soc Sec No. XXX-XX- Date of (Choose ONE only) I hereby authorize PCHS to: ____ Get your records from: ~OR~ ____ Release your records to: Name: Address: City: State: Zip Code: Phone: Fax: Please initial the information to be released or obtained: Demographic Information Only Medical Records Behavioral/Mental Health/Integrated Assessment Dental Records Psychological Tests/Reports Lab/X-ray Results Psychiatric Evaluation/Record(s)/Assessment(s) Other (explain): All of my PCHS Health Care Records From date: _____________ To date: _______________ I understand that this request may include diagnoses, consultations, evaluations, Integrated Assessments, Treatment Plans, tests/results, medications, and treatment for all Medical, Behavioral Health, Psychological, Psychiatric, Substance and Alcohol Use and/or Dental records. I understand that federal or state law may restrict re-disclosure of HIV/AIDS, mental health information, genetic testing information, and drug/alcohol diagnosis, treatment, or referral information. If Behavioral/Mental Health/Integrated Assessment, or Psychiatric Evaluation/Records/Assessment are initialed above (marked with “”), please initial the appropriate yellow box below as required by Federal Regulations. I understand and that the information marked with a “” above will be disclosed ONLY if I place my initials in the applicable space below next to the type of information requested: HIV/AIDS testing information/results Mental Health specific visits Substance/Alcohol Use treatment visits/progress Genetic testing
ROI%20Authorization%20PCHS_FORMS%20INTEGRATED2017%2012.20.17.docx