John J. Eck, M.D.                      Center for Lifetime Health

300 E Bannock Street

Boise, ID  83712

 

AUTHORIZATION TO RELEASE

CONFIDENTIAL MEDICAL INFORMATION

 

___________________________________                 _______________

PATIENT NAME                                                            DATE OF BIRTH

___________________________________               _______________

ADDRESS                                                                 PHONE NUMBER

_____________________  _________ _________      _______________

CITY                                              STATE               ZIP                        E-MAIL

 

I hereby request that a copy or summary of my records, INCLUDING LABORATORY or X-RAY reports that you may have which contain information relevant to my present and future diagnosis and/or treatment be released.

                                 

TO:  Center for Lifetime Health      FROM: St. Luke’s Family Health

       300 E Bannock Street                     3090 Gentry, Suite #200

       Boise ID  83712                             Meridian, ID  83642

 

SPECIFIC AUTHORIZATION

 

Substance Abuse                                                                     Mental Health                             HIV (AIDS)

                                                                                 Treatment Information                     Test Results

 

I acknowledge that data to be released may include material that is protected by federal law and that is applicable to ANY or ALL of the above.  My signature below authorizes release of all such information except as otherwise specified. 

 

I understand I do not have to sign this authorization in order to get health care benefits (treatment, payment or enrollment).  However, I do have to sign an authorization from:

 

·          To take part in a research study.

or

·          To receive health care when the purpose is to create health information for a third party.

I may revoke this authorization in writing.  If I did, it would not affect any actions already taken by Center for Lifetime Health based upon this authorization.  I may not be able to revoke this authorization if its purpose was to obtain insurance.  Once this office discloses health information, the person or organization that receives it may re-disclose it.  Privacy laws may no longer protect it.

 

 

 

_____________________________                     _____________________                       _____________            

Patient or legally authorized                                Date                                         Time

individual signature

 

_____________________________                     ____________________________________________________

Printed name if signed on behalf                                       Relationship (parent, legal guardian, personal representative, etc.

of the patient

 

PLEASE MAIL OR FAX TO:                          Phone: (208) 342-7400

Center for Lifetime Health                         Fax:     (208) 342-1879

300 E. Bannock Street

Boise,  ID   83712