Free Medical Release Form 20Free Medical Release Form 20
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AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
(Complete in full. See reverse side for important information.)
Name of Patient
Street Address
City, State, Zip code
Date of Birth
I authorize the use and/or release of my protected health information as described below. I understand
that the information used or released as a result of this Authorization may no longer be protected by
federal privacy laws and may be further used or released by persons or organizations receiving it without
obtaining my authorization. I may refuse to sign this Authorization, which will not affect my ability to
obtain treatment or payment of claims. I have the right to revoke this Authorization by providing written
notice to Dean Health System, Health Information Services Department. Revocation of this Authorization
will not affect any action taken before receipt of the written revocation.
2. AUTHORIZE:
3. TO RELEASE PROTECTED HEALTH INFORMATION TO:
______________________________________________________