| 1. I , ______________________________
Authorize PHTC, Inc., to disclose the following information from the health records of: Patient Name: ________________ Date of birth:___________________ Address:_______________________________________________ Telephone: ____________________________ Social Security Number: ________________________________ Covering the period (s) of healthcare: From (date) ____________ To (date) _____________ From (date) ____________ To (date) _____________ 2.Information to be disclosed: [ ] Complete health records (s)
[ ] Progress Notes
[ ] Discharge Summary [ ] Laboratory Tests
[ ] History and Physical Examination [ ] X-Ray Reports
[ ] Consultation Reports [ ] Photographs, videotapes, digital or other images
[ ] Other (please specify) __________________________
_______________________________________________ 3. This information is to be disclosed to_____________________________ For the purpose of:______________________________________________ 4.I understand this authorization may be revoked in writing at any time, except to the extent that action has been taken in reliance on this authorization. Unless otherwise revoked, this authorization will expire on the following date, event or condition: ______________________________________________________________ 5. The facility, its employees, officers, and physicians are hereby released from any legal responsibility or liability for disclosure of the above in information to the extent indicated and authorized herein. ______________________________________________________________
Signature of Patient or Legal Representative Date ______________________________________________________________
Signature of Witness Date | 
