fbpx

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 Information

MM slash DD slash YYYY

This is to authorize the release of medical information regarding the above identified person.

From or To:

From or To:

Jordan River Women's Health

3584 W. 9000 S. Suite 206 West Jordan, UT 84088
Ph: (801) 561-2227 Fax: (801) 561-5353

*Please note: Releases without either a phone number or an address cannot be processed.

Date Range:

MM slash DD slash YYYY
MM slash DD slash YYYY
Reason for Transfer:*

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.

MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.

© 2017 Jordan River Women's Health. All Rights Reserved.