Hawaii Authorization to Release Medical Information FormHawaii Authorization to Release Medical Information FormHawaii Authorization to Release Medical Information Form
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640 Ulukahiki Street
Kailua, Hawaii 96734-4498
www.castlemed.org

Department: __________________________
Phone #: __________ Fax#: _____________

Authorization to Release Medical Information
*Patient Name: ___________________________________ *Date of Birth: _________________
Address: ________________________________________ SSN#: ________________________
City/State/Zip: ___________________________________ Phone: ________________________
*Check One:  Pick up  Mail to above address
 Please OBTAIN Information FROM:
 Please SEND Information TO:
___________________________________
Name of physician, hospital, or other

*FOR THE PURPOSE OF:
 Patient Care
 Self
 Insurance Claim
 Other
*List specific dates of records to be released:

___________________________________
Street Address

*Duration: This authorization shall begin
immediately and remain in effect until:
(date) _________________________.

___________________________________
City/State/Zip
Fax Number

*PLEASE SPECIFY WHAT TYP