AUTHORIZATION FOR REQUEST OF MEDICAL RECORDS
I hereby authorize the release of information from the medical record of:
Please Release Information To:
Preferred Medical Group: Centralized Fax: (334) 664-0466
Preferred Medical Group Location:
Phenix City | 3700A S. Railroad St. Phenix City, AL 36867 | (334) 664-0463
Opelika Hwy 280 l 5809 Highway 280 East Opelika, AL 36804 | (334) 275-3059
Fort Mitchell | 2 Gilmore Road Fort Mitchell, AL 36856 | (334) 664-1960
Opelika Executive Park | 2112 Executive Park Drive Opelika, AL 36801 l (334) 749-2007
Immunization Record/Growth Chart / Last well Visit
Complete Medical Records
Purpose of Disclosure:
Other (Please Specify)
Informed Consent for Release of Confidential Information.
I understand that I may revoke this consent in writing at any time except to the extent action has been taken.
I understand that this consent will expire 90 days after the date of my signature unless otherwise specified.
I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by Federal Privacy Regulations.
Relationship to Patient