Phone:  (907) 569-1333
Fax:  (907) 569-1433

Patient Portal

Release of Information (ROI)

Upload Patient ID and Insurance Card(s)

 

Consent to Release and Disclose Protected Health Information

, the patient,

Continuation of Care
Second Opinion
Personal Use
Other:


Please check all appropriate boxes.

Summary of Medical History / Treatment
Laboratory / Diagnostic Test
Radiology Records
All records, including any records in these subject areas:
HIV /AIDS
Sexually Transmitted Disease
Mental Illness or Mental Health Treatment
Drug and Alcohol Abuse / Treatment
Other:

 

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The staff may discuss my medical condition and treatment with those persons listed above. This consent is subject to revocation at any time except to the extent that the persons.organization which is to make the disclosure has already taken action in reliance on it.

Re-Disclosure Prohibited: This information has been disclosed from records whose confidentiality's protected by state or federal law (42 CFR part 2). These laws prohibit making any further disclosure of this information without the specific written consent of the person whom it pertains, or as otherwise permitted by law.


I understand I may revoke this consent at any time. or in 180 days unless otherwise specified.

By typing you name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application