Priority Urgent Care Corp Form

Authorization For Use or Disclosure of Medical Record Information

Patient Information

First Name:

Last Name:

Email:

Phone:

Date of Birth:

Patient Address:

City:

State:

Zip:

I hereby Authorize PRIORITY URGENT CARE to disclose / obtain my health information including if applicable information relating to the diagnosis and treatment of mental illness, drug and/or alcohol treatment, HIV/AIDS, including HIV antibody and antigen testing, and HIV/AIDS diagnosis or treatment, Genetic testing, Sexually Transmitted Diseases

Please choose one:

Release my medical record information to Obtain medical information from

Name/Facility:

Attention:

Address:

Phone:

Fax #

Purpose of Request:

Personal Referral Continuum of Care Legal Insurance Other

Specific Records to be released: Please provide the specific information as outlined below for Date(s) of Treatment