REQUEST FOR RELEASE OF INFORMATION
Mobile Infirmary | P 251-435-2286/ F 251-435-5884
Infirmary LTAC | P 251-435-1206/ F 251-435-5884
Thomas Hospital | P 251-279-1570/ F 251-279-1490
North Baldwin Infirmary | P 251-580-1754/ F 251-937-7305



  
  Name
    
    Date of Birth

  
  Address

    
    Phone Number/ Fax Number

  
  City, State, Zip Code

    
    Social Security Number (last 4 digits)


  I hereby authorize:         
   
  to release to  
                           Name and Address

This consent and authorization may include, but is not limited to, the release of medical, psychological, psychiatric, alcohol, drug abuse, STD and HIV/AIDS information.

Purpose of Disclosure:


The specific information to be released is:





  

Dates of Hospitalization or Visit:

Medium to be used:        

I understand that this consent is revocable, except to the extent that action has already been taken in reliance thereon. Request for revocation of this authorization must be in writing. This authorization will expire (i) after 1 year, (ii) after the disclosure is made, or (iii) the date specified here: , to accomplish the purpose of the disclosure stated above.

  
Electronic Signature of Patient or Representative            Date/Time


Relationship (if other than patient)

  
Electronic Signature of Witness                   Date/Time


Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and is no longer protected under Title 45, CFR. Infirmary Health may not condition treatment or payment on whether you sign this authorization, unless this authorization is for the provision of research-related treatment or for the creation of health information for disclosure to a third party.