Designation of Representative(s)

Authorize individuals to receive your health information

Patient Information

Last Name *

First Name *

Former Name

Date of Birth *

I designate the person(s) listed below as authorized representatives, allowing the release of my health information.

Authorized Representative #1

Name *

Address

Phone

Authorized Representative #2 (Optional)

Name

Address

Phone

To Be Released From:

Vally Medical Group

82 Pu'uhonu Place #202-203, Hilo, HI 96720

Phone: (808) 935-6353 | Fax: (888) 511-6031

Email: vallymedicalgroup@gmail.com

Acknowledgments *

I understand and acknowledge that my medical records may include information regarding treatment for physical illness, alcohol/drug abuse, and/or HIV/AIDS test results or diagnosis. I understand that the information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by Federal and State law. However, I understand the information related to alcohol or drug treatment services (42 CFR Part 2) may not be disclosed or redisclosed without my authorization. I understand that my healthcare information is protected by state and federal regulations that protect the confidentiality of this information and that my healthcare information may not be released/disclosed without my written authorization, unless otherwise provided for by the law.

Patient Signature (Type Full Name) *

Date *

Form Submitted

Patient Information

Authorized Representative #1

Authorized Representative #2 (Optional)

To Be Released From:

Acknowledgments *