Record Release Form

NORTH BEND MEDICAL CENTER, INC.

AUTHORIZATION TO USE/DISCLOSE HEALTH INFORMATION

Medical Records Fax# 541-266-4591

This authorization must be written, dated and signed by the patient or by a person authorized by law to give this authorization.

TYPE OF INFORMATION TO BE RELEASED:

* Must Be Initialed To Be Included In Other Documents

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Your health care & payment for that health care cannot be conditioned upon receipt of this signed Authorization unless your health care or treatment is for the purpose of: (1) Creating health information about you to be disclosed to a third party; or (2) For the purpose of research. You have the right to revoke this Authorization at any time, provided that you do so in writing. If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any used or disclosures already made with your permission. To revoke this Authorization, please send a written statement to the attention of Privacy Officer at North Bend Medical Center, Inc. – 1900 Woodland Drive – Coos Bay, OR 97420 that identified the data you signed this Authorization, the recipient of the information identified in this Authorization, and state that you are revoking the Authorization. The information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and no longer be protected under federal law.
This Authorization will expire on the earlier of: Or 1 year from the date of signing.

Restrictions - Initial & Complete if Applicable:

This Authorization is Limited To The Following Dates Of Service:
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From:To:
This Authorization is Limited To The Following Treatment:
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PATIENT AUTHORIZATION TO RELEASE INFORMATION

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DATE:
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NBMC Form MR 50-113-019 Rev. 08/12
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