Mindy Miller MD Linda Peterson MD,
401 S. Park Ave.Montrose, CO81401970-240-8199
Authorization for Release of Medical Information
I hereby authorize the release of information from the medical record of:
Patient Name: ______Date of Birth: ______
Physician/Office providing the information:(Please provide phone/fax numbers if available.)
______
______
______/ Name/Fax number of Physician/Officereceiving information. Please FAX to:
Mindy Miller, MD
Linda Peterson, MD
FAX # (970) 249-9186
Please Release the Following:
______All Records / ______Radiology Reports / ______Consult Notes______EKG Reports / ______Lab Reports / ______Immunizations
______Procedure Reports
______Substance Abuse Info / ______Progress Notes
______Appointment Confirm / ______History/ Physical Exam
______Updates/Summaries
______Other ______
Purpose of Need for Disclosure:
______Continuity of Care / ______Personal Use / ______Disability Determination______Other ______
I understand that the information released is for the specific purpose stated above. Any other use of this information without thewritten consent of the patient is prohibited. I further understand that I may revoke this consent (in writing) at any time except to theextent that action has been taken in reliance on it. This consent will expire on: (___/___/_____).
______
Signature of Patient or Legal Representative Date
______
Relationship to Patient
Psychotherapy Notes: This authorization does not permit the disclosure of psychotherapy notes.
COMPLETE ONLY IF INFORMATION IS TO BE RELEASED DIRECTLY TO PATIENT:
I understand that my medical record may contain reports, test results, and notes that only a physician can interpret. I understand andhave been advised that I should contact my physician regarding the entries made in my medical record to prevent mymisunderstanding of the information contained in these entries.
I will not hold this practice liable for any misinterpretation of the information in my medical record as
a result of not consulting my physician for the correct interpretation.
______
Signature of Patient or Legal Representative Date
______
Relationship to Patient
Date request completed______# pages copied ______Initials ______
Revised 07/2009Release of Records