Common use of Authorization for Release of Protected Health Information Clause in Contracts

Authorization for Release of Protected Health Information. I hereby authorize to disclose Protected Health Information (PHI) as deemed below. Patient: Requestor (if other than patient): Name Soc. Sec. # DOB Name Relationship Source of Legal Authority Name & Address of who to receive health records/information: Cholla Medical Group, Inc. 00000 X. 00xx Xxxxxx, Xxxxx 0 Phoenix, Arizona 00000-0000 Phone # 000-000-0000 Fax # 0-000-000-0000 ☐ I wish to have the following records copied and I will pick them up at your facility ☐ I request the facility copy the following records and fax/send them to the above address I request the release of all medical records created between Date and ☐ ☐ ☐ ☐ Legal Authority Request: I am the Patient noted above I am the Patient’s legal representative I am the Patient’s Power of Attorney I am the Patient’s legal Guardian Requestor’s Initials I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse) for use in medical treatment or consultation, billing or claims payment, or other purposes as I may direct. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization. If signing as a POA, please include a copy of documentation, as some providers will not release records without additional documentation. Signature__________________________________________________ Date______________________

Authorization for Release of Protected Health Information. I hereby authorize to disclose Protected Health Information (PHI) as deemed below. Patient: Requestor (if other than patient): Name Soc. Sec. # DOB Name Relationship Source of Legal Authority Name & Address of who to receive health records/information: Cholla Medical Group, Inc. 00000 X. 00xx Xxxxxx, Xxxxx 0 Phoenix, Arizona 00000-0000 Phone # 000-000-0000 Fax # 0-000-000-0000 ☐ ☐ I wish to have the following records copied and I will pick them the up at your facility ☐ I request the facility copy the following records and fax/send them to the above address I request the release of all medical records created between Date and _ ☐ ☐ ☐ ☐ Legal Authority Request: I am the Patient noted above I am the Patient’s legal representative I am the Patient’s Power of Attorney I am the Patient’s legal Guardian Requestor’s Initials I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse) for use in medical treatment or consultation, billing or claims payment, or other purposes as I may direct. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization. If signing as a POA, please include a copy of documentation, as some providers will not release records without additional documentation. Signature__________________________________________________ Date_______________________ Relationship to Patient Name of Person Completing this Form 00000 X. 00xx Xxxxxx, Xxx. 0, Xxxxxxx, XX 00000-0000 xxxxxxxx@xxxxxxxxxxxxx.xxx Office: 000-000-0000 xxx.xxxxxxxxxxxxxxxxxx.xxx Fax: 0-000-000-0000

Authorization for Release of Protected Health Information. I hereby authorize to disclose Protected Health Information (PHI) as deemed below. Patient: Requestor (if other than patient): Name Xxxx X. Xxx Soc. Sec. # 000-00-0000 DOB 07/04/1943 Name Xxxx X. Xxx Relationship wife Source of Legal Authority medical POA Name & Address of who to receive health records/information: Cholla Medical Group, Inc. 00000 X. 00xx Xxxxxx, Xxxxx 0 Phoenix, Arizona 00000-0000 Phone # 000-000-0000 Fax # 0-000-000-0000 ☐ I wish to have the following records copied and I will pick them up at your facility ✔☐ I request the facility copy the following records and fax/send them to the above address I request the release of all medical records created between Date and ☐ ☐ ☐ ☐✔ ☐ Legal Authority Request: I am the Patient noted above I am the Patient’s legal representative I am the Patient’s Power of Attorney I am the Patient’s legal Guardian Requestor’s Initials I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse) for use in medical treatment or consultation, billing or claims payment, or other purposes as I may direct. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization. If signing as a POA, please include a copy of documentation, as some providers will not release records without additional documentation. Signature__________________________________________________ DateDate___0__2__/_2_7__/_1_9_______________________ Relationship to Patient_wife Name of Person Completing this Form_J_a_n_e__M_._D__o_e SAMPLE MEDICAL POWER ATTORNEY FULL POWER OF ATTORNEY Date: I, , the undersigned, of , do hereby confer full power of attorney on , of as true and lawful attorney-in-fact for me and in my name, place and xxxxx, and on my behalf, and for my use and benefit, regarding the following: FIRST: To ask, demand, litigate, recover, and receive all manner of goods, chattels, debts, rents, interest, sums of money and demands whatsoever, due or hereafter to become due and owing, or belonging to me, and to make, give and execute acquittances, receipts, satisfactions or other discharges for the same, whether under seal or otherwise; SECOND: To make, execute, endorse, accept and deliver in my name or in the name of my aforesaid attorney all checks, notes, drafts, warrants, acknowledgments, agreements and all other instruments in writing, of whatever nature, as to my said attorney-in-fact may seem necessary to conserve my interests; THIRD: To execute, acknowledge and deliver any and all contracts, debts, leases, assignments of mortgage, extensions of mortgage, satisfactions of mortgage, releases of mortgage, subordination agreements and any other instrument or agreement of any kind or nature whatsoever, in connection therewith, and affecting any and all property presently mine or hereafter acquired, located anywhere, which to my said attorney-in-fact may seem necessary or advantageous for my interests; FOURTH: To enter into and take possession of any lands, real estate, tenements, houses, stores or buildings, or parts thereof, belonging to me that may become vacant or unoccupied, or to the possession of which I may be or may become entitled, and to receive and take for me and in my name and to my use all or any rents, profits or issues of any real estate to me belonging, and to let the same in such manner as to my attorney shall seem necessary and proper, and from time to time to renew leases; FIFTH: To commence, and prosecute on my behalf, any suits or actions or other legal or equitable proceedings for the recovery of any of my lands or for any goods, chattels, debts, duties, and to demand cause or thing whatsoever, due or to become due or belonging to me, and to prosecute, maintain and discontinue the same, if he or she shall deem proper; SIXTH: To take all steps and remedies necessary and proper for the conduct and management of my business affairs, and for the recovery, receiving, obtaining and holding possession of any lands, tenements, rents or real estate, goods and chattels, debts, interest, demands, duties, sum or sums of money or any other thing whatsoever, located anywhere, that is, are or shall be, by my said attorney-in-fact, thought to be due, owing, belonging to or payable to me in my own right or otherwise; SEVENTH: To appear, answer and defend in all actions and suits whatsoever that shall be commenced against me and also for me and in my name to compromise, settle and adjust, with each and every person or persons, all actions, accounts, dues and demands, subsisting or to subsist between me and them or any of them, and in such manner as my said attorney-in-fact shall think proper; hereby giving to my said attorney power and authority to do, execute and perform and finish for me and in my name all those things that shall be expedient and necessary, or which my said attorney shall judge expedient and necessary in and about or concerning the premises, or any of them, as fully as I could do if personally present, hereby ratifying and confirming whatever my said attorney shall do or cause to be done in, about or concerning the premises and any part thereof. Xxxxxx conferred on said attorney-in-fact shall not be restricted or limited by the aforementioned specifications regarding situation of representation. The rights, powers and authority of said attorney-in-fact granted in this instrument shall commence and be in full force and effect on , (Month & Day) , (Year) and such rights, powers and authority shall remain in full force and effect thereafter until I give notice in writing that such power is terminated. It is my desire, and I so freely state, that this power of attorney shall not be affected by any subsequent disability or incapacity that may befall me. FURTHERMORE, upon a finding of incompetence by a court of appropriate jurisdiction, this power of attorney shall be irrevocable until such time as said court determines that I am no longer incompetent. Signature I, , whose name is signed to the foregoing instrument, having been duly qualified according to the law, do hereby acknowledge that I signed and executed this power of attorney; that I am of sound mind; that I am eighteen (18) years of age or older; that I signed it willingly and am under no constraint or undue influence; and that I signed it as my free and voluntary act for the purpose therein expressed. Signature My commission expires on