Patient's InformationPatient's Full Name(Required) First Last DOB(Required) MM slash DD slash YYYY Phone Number(Required) Email(Required) Patient's Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I authorize St. Louis Medical Clinic or a representative to disclose the following medical information to:Physician's InformationName of Facility / Physician(Required) Physcian's Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code This authorization extends to only documents designated below:Designated Record Set Designated Record Set From(Required) MM slash DD slash YYYY To(Required) MM slash DD slash YYYY Admission / Discharge Summary Admission / Discharge Summary From(Required) MM slash DD slash YYYY To(Required) MM slash DD slash YYYY Immunization Record Immunization Record AIDS (Acquired Immunodeficiency) / HIV (Human Immunodefiency Virus) Information (Only release to patient) AIDS (Acquired Immunodeficiency) / HIV (Human Immunodefiency Virus) Information (Only release to patient) Mental Health (including depression) or alcohol / drug abuse treatment (only release to patient) Mental Health (including depression) or alcohol / drug abuse treatment (only release to patient) X-Ray films and report(s) X-Ray films and report(s) Mammogram(s) and report(s) Mammogram(s) and report(s) For the purpose of(Required) Genetic testing (only release to patient) Genetic testing (only release to patient) Entire Medical Record Entire Medical Record Other Other (Must be specified) Other(Required) State of charges or payments State of charges or payments By checking this box, I consent to the following:(Required) I authorize St. Louis Medical Clinic or a representative to disclose the following medical information.This authorization is given freely with the understanding: 1. Any and all records, whether written, oral or in electronic format, are confidential and cannot be disclosed without prior written consent. 2. Any photocopy of fax of this authorization will be as valid as the original. 3. I may revoke this authorization at any time, except where information has already been obtained. This Authorization is valid for a ninety (90) day period from the date it is signed. 4. St. Louis Medical clinic, its employees, officers, and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein. 5. St. Louis Medical Clinic contracts with third party vendors to provide copies of medical records. These vendors may send an invoice directly from their home office for any charges associated with your copies.Today's Date(Required) MM slash DD slash YYYY Δ
