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Authorization To Release Confidential Medical Information

I hereby authorize:

Facility/Physician name: _____________________________________

Address: ________________________________________________

City/State/Zip: ____________________________________________

To release the following information from the medical records of:

Name: _____________________________________ Daytime phone: _________________

Date of Birth: _____________ Dates of Treatment: From ____________ To ____________

Information to be released (check all that apply):

___ Complete medical records

___ All Lab results (or specify - ___________________________________)

___ Diagnostic procedure reports (x-ray, ultrasound, biopsy, etc) Specify __________________

___ Other - Specify __________________________________________________________

Information is to be released to:

Pat Elliott, ND
1155 N State ST, Suite 610
Bellingham, WA 98225
(360) 647-0228

Please fax requested records to (360) 671-5218 or mail to above address

This authorization is valid for 60 days from the date signed. I understand this consent can be revoked at any time to the extend that disclosure made in good faith has already occurred in reliance on this consent.

I also understand that my records are protected under the federal and state confidentiality regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations.

_____________________________________   ______________________________

Patient signature                                                            Date