Medical Records Release

Authorization for Use or Disclosure of Health Information

First Name

Last Name

Former Name

Date of Birth

Mailing Address

Home Phone

Cell Phone

Exchange Information With:

Name of Person / Facility

Address

Phone

Fax

Release To/From:

Vally Medical Group

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

P: (808) 935-6353 | F: (888) 511-6031

I acknowledge records may include info on physical illness, alcohol/drug abuse, or HIV/AIDS. I understand info disclosed may be re-disclosed by recipient and no longer protected. I understand my info is protected by regulations and requires written authorization.

Signature (Type Name)

Date

Authorization Sent

Exchange Information With:

Release To/From: