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Release of Information

  • AUTHORIZATION FOR USE & DISCLOSURE (RELEASE OR REQUEST) OF PROTECTED HEALTH INFORMATION

    This form will authorize Meridell Achievement Center (MAC) to use and disclose or request certain health information about the person named below. All items must be completed and the authorization signed to be valid. I understand this authorization is voluntary, I may refuse to sign this authorization and I understand that MAC may not withhold treatment because I refuse to sign this authorization.
  • I authorize MAC to disclose or request health information, as described below, from the medical record of:
  • Date Format: MM slash DD slash YYYY
  • The information specified below may be released to or requested from:
  • The specific purpose(s) for this disclosure is/are (check your selection):
  • SPECIFY EXACT INFORMATION TO BE RELEASED: (1) Place a check next to the specific information needed, (2) List the dates of treatment