Form-Authorization for Release of Medical InformationForms Authorization for Release of Medical Information Authorization for Release of Medical Information "*" indicates required fields JORDAN RIVER WOMEN’S HEALTH, P.C. Spencer Colby, M.D.Scott Epstein, D.O.Denise Nippert, M.D. Authorization for Release of Medical InformationPatient Name* Date* MM slash DD slash YYYY Social Security Number:* DOB:* Address:* Apt. City:* State:* Zip:* This is to authorize the release of medical information regarding the above identiied person. From:Physician/ Clinic:* Phone* Fax:* Address:* City:* State:* Zip:* To: Jordan River Women's Health 3584 W. 9000 S. Suite 206 West Jordan, UT 84088Ph: (801) 561-2227 Fax: (801) 561-5353 *Please note: Releases without either a phone number or an address cannot be processed. Information to be released:* Date Range:Date From:* MM slash DD slash YYYY Date To:* MM slash DD slash YYYY Reason for Transfer:* Permanent Transfer Continuation of Care Second Opinion Dissatisfied* I Acknowledge and hereby consent to such that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results andkor AIDS information* This Authorization is valid for ISO days from date of signing and may be revoked at any time by sending a written request to Jordan River Women's Health, P.C. prior to the expiration date. Any such withdraw will not aaect any information or records disclosed prior to written notice of withdraw. I understand that authorizing disclosure of my protected health information is voluntary and that I need not sign this authorization in order to assure medical treatment. I further understand that the disclosure of this information carries with it the potential for unauthorized redisclosure and the information may no longer be protected by Federal conndentiality rules.Signature of Patient or Legal Representative*Relationship to Patient Print Name* Email* Date* MM slash DD slash YYYY CAPTCHANameThis field is for validation purposes and should be left unchanged.