AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS & HEALTHCARE INFORMATION

P.R.I.M.A., Inc. 2178 Mendon Rd, Suite 100 Cumberland, RI 02864 P: (401) 333-5201, F: (401) 333-5215

Please correct the errors described below.

I hereby authorize the use or disclosure of my individually identifiable health information as described below.

PATIENT INFORMATION

Patient First Name

Patient Last Name

Date of Birth:

Phone Number:

Patient Address:

City/Town, State, Zip

I hereby authorize P.R.I.M.A., Inc. to:

OBTAIN FROM RELEASE TO

Name:

Telephone:

Address:

City:

State:

Zipcode:

INFORMATION TO BE RELEASED

Please check all that apply:

Immunizations

Laboratory, x-ray, or other diagnostic testing

Office notes for date(s) of service:

Complete medical record

*Please select each box to authorize disclosure:

Substance abuse testing/treatment

HIV/AIDS testing/treatment

Mental health evaluation/treatment, social service counseling or developmental disability records

STD testing/treatment

Office notes for date(s) of service is selected, Please specify:

Or, please indicate time period to be released:

PURPOSE

Please indicate reason for record release:

Medical Care

Transfer of care

Insurance

Legal

School

Personal

I understand and acknowledge that I am voluntarily initialing this authorization and that the information that is released will no longer be protected under the federal privacy laws. I understand that this authorization will expire 1 year from the date of initialing unless revoked earlier by me in writing and cannot be withdrawn after the disclosure.

Name and Initials of Legal Guardian or self (if over 18 years of age):

Relationship to Patient:

Date:

Your information will be encrypted.

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