Authorization For Release to Highlands

Authorization for Release of Info to Highlands Oncology Group

Releasing Dr.'s Name, Address, and Phone Number*
Please list the name, address, and phone number of the physician who will be releasing your information to Highlands.
Authorization to Release Patient Information*
I authorize my doctor and clinic as stated above to release my information to Highlands Oncology Group.
Patient's Name*
First Middle Last
Hidden
Email
Patient's Medical Record Number*
Patient's Date of Birth*
MM slash DD slash YYYY
Patient's Phone Number*
Information is to be limited to the following dates (if applicable)
Only enter dates below if you’d like your information to be limited to a certain period of time.
Beginning Date
MM slash DD slash YYYY
Ending Date
MM slash DD slash YYYY
Purpose of release is at the request of the patient or:
- Insurance Company
- Medical Care
- Other
Expiration Date
This authorization will expire 90 days from the date on which it was signed unless I specify a different time period. I understand that I may revoke this authorization at any time by giving written notice. A revocation of this authorization will not apply to records already released in reliance upon the authorization. A photocopy of this signed authorization shall constitute a valid authorization.
Expiration Date
MM slash DD slash YYYY
Permissions
I understand that once the above information is disclosed, it may be re-disclosed by the designated recipient and the information may no longer be protected by federal privacy laws. Treatment, payment, enrollment, or eligibility for benefits will not be conditioned on your signing this authorization.
Consent*
I agree to the statement above.

Authorization For Release to Highlands

Authorization for Release of Info to Highlands Oncology Group

Information is to be limited to the following dates (if applicable)

Expiration Date

Permissions