Authorization for Release of Medical Information

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This field is for validation purposes and should be left unchanged.
I hereby voluntarily authorize the use and/or disclosure of my health information as described below. I understand that if the entity authorized to receive the information is not a health plan or health care provider; the released information may no longer be protected by federal privacy regulations. This authorization is effective for one year from the date on which it was signed. I understand that I may revoke this authorization at any time, except to the extent that action has already been taken in reliance upon it, by giving written notice to Madison County Health Care System. I understand that I have the right to inspect the information to be disclosed upon the proper notification to and under conditions established by the organization.
Patient Identification
Name*
First Middle Last
- Last 4 digits of Social Security #*
- Date of Birth*
  Month
  Day
  Year
- Contact Phone #*
- Contact Email Address*
Any previous names under which records may be kept:

Provider Information
Who is to send or disclose the information?
Provider Name*
- Madison County Memorial Hospital
- Health Trust Physicians Clinic / Earlham Medical Clinic
- Other Entity (please specify below)
Name of Other Entity
- Phone
- Fax
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Recipient Information
Who is to receive the information?
Name of Recipient*
- Phone Number*
- Fax Number*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Patient Identification