This authorization must be written, dated, and signed by the patient or by a person authorized by law to give authorization.
I authorize (name of hospital/health care provider):
To release a copy of the medical information for
(name of patient):
To: Thomas Lee Abshier, N.D.
Margo D. Nissley-Abshier, N.D.
1414 NE 109th Avenue Portland, OR 97220
fax: (503) 255-1888
The information will be used on my behalf for the following purpose(s):
Continuing Care ___, Diagnosis ___, Specialty Treatment ___,
By initialing or placing an “x” by the spaces below, I specifically authorize the release of the following medical records, if such records exist:
All hospital records (including nursing records and progress notes)
Transcribed hospital reports
Medical records needed for continuity of care
Most recent five year history
Emergency and urgent care records
Diagnostic imaging reports
Clinician office chart notes
Please send the entire medical record (all information) to the above named recipient. The recipient understands this record may be voluminous and agrees to pay all reasonable charges associated with providing this record.
The following items must be initialed to be included in other documents.
*HIV/AIDS related records
*Mental health information
*Genetic testing information
*Drug/alcohol diagnosis, treatment or referral information (Federal regulations require a description of how much and what kind of information is to be disclosed.)
This authorization is limited to records regarding the following treatment:
This authorization is limited to records from the following time period:
This authorization is limited to a worker’s compensation claim for injuries on a specific date: (Date)
This authorization may be revoked at any time. The only exception is when action has been taken in reliance on the authorization. Unless revoked earlier, this consent will expire 180 days from the date of signing or shall remain in effect for the period reasonably needed to complete the request.
(Date) (Signature of Patient)
(Date) (Signature of person authorized by law)