Mail to: Health Information Management 1201B Sam Perry Blvd, Fredericksburg, VA 22401 or fax to: 540-741-1622

 IauthorizetheMaryWashingtonMedicalGrouptoreleasetheinformationfromtherecordof:

Mail to: Health Information Management 1201B Sam Perry Blvd, Fredericksburg, VA 22401 or fax to: 540-741-1622

PatientName:

DateofBirth:

SocialSecurityNumber: DaytimePhoneNumber:

Mail to: Health Information Management 1201B Sam Perry Blvd, Fredericksburg, VA 22401 or fax to: 540-741-1622

Address:

Documentationcanbereleasedelectronicallyifstoredinanelectronicmedia.

Preferredmedia:Paper CD OnlineRecordeDeliveryemailaddress:

DatesofService:to

Information tobe released:

 Complete Medical Record from theGenerations of Women Practice

Person/Facility to receive information:

Street______City:______State:______ZipCode:

Thisinformationisbeingdisclosedforthefollowingpurpose:

Authorization to Release Information:

1.Iunderstandthatauthorizingthedisclosureofthishealthinformationisvoluntary.Icanrefusetosignthisauthorization.Ineednotsignthisforminordertoensuretreatment.IunderstandthatImayinspectorcopytheinformationtobeusedordisclosed,asprovidedinCFR164.524.Iunderstandthatanydisclosureofinformationcarrieswithitthepotentialforanunauthorizedredisclosureandtheinformationmaynotbeprotectedbyfederalconfidentialityrules.IfIhavequestionsaboutdisclosureofmyhealthinformation,IcancontacttheHealthInformationManagementDepartmentat(540)741-1620.

2.IunderstandthatIhavetherighttorevokethisauthorizationatanytimebynotifyingthePrivacyOfficerinwritingofmyrevocation,exceptwhereactionshavealreadybeentakeninrelianceuponthisauthorization.

IfIdonotrevokeitearlier,thisauthorizationwillexpireonthedate,event,orconditiondescribedas:(ifnonespecified,thisauthorizationwillexpire6monthsafterthedatespecifiedbelow).

3.IunderstandthatIwillbegivenacopyofthisauthorizationform,aftersigning.Iunderstandthatcopyingchargeswillbeappliedatarateof:$0.12perpage. If delivered electronically, a flat fee of $6.50 will be applied.A copyingfeewillnotbechargedifIchooseto have theMaryWashingtonMedicalGroupforwardmyrecordsto anewprovider.

SignatureofPatient or Legal Representative:Date:

 ParentorLegalGuardianMedicalPowerofAttorney NextofKinDeceasedExecutorofEstate

*****************************************************************************************

Department Use Only

Mail to: Health Information Management 1201B Sam Perry Blvd, Fredericksburg, VA 22401 or fax to: 540-741-1622

MRN

ID Verified (Type and ID#)

Mail to: Health Information Management 1201B Sam Perry Blvd, Fredericksburg, VA 22401 or fax to: 540-741-1622

ProcessedBy:DateProcessed:PagesProvided:

MaryWashingtonMedicalGroup

AuthorizationtoReleaseConfidentialMedicalInformation