Release of Information Form

Please correct the errors described below.

ALASKA DIGESTIVE AND LIVER DISEASE, LLC

Ronald J Boisen, M.D. | Daryl M. McClendon, M.D. | Jeffrey W. Molloy, M.D.

Consent to Release and Disclose Protected Health Information

Information to be Disclosed

Person / Organizations TO Receive Information

The staff may discuss my medical condition and treatment with those persons listed above. This consent is subject to revocation at any time except to the extent that the persons/organization which is to make the disclosure has already taken action in reliance on it.

Re-Disclosure Prohibited: This information has been disclosed from records whose confidentiality's protected by state or federal law (42CFR part 2). These laws prohibit making any further disclosure of this information without the specific written consent of the person whom it pertains, or as otherwise permitted by law.

or in 180 days unless otherwise specified.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Your message will be encrypted and can only be read by Alaska Digestive and Liver Disease.