top of page

Authorization For Release Of Health Information

NOTE: ALL Sections Must be Completed

Multi-line address
Birth Date:
Month
Day
Year

I authorize WestSide Ambulance to release my health information, as specifically described below:

Multi-line address
Purpose of Request to Release:
Information to be disclosed:

I UNDERSTAND THAT:

  • This Authorization will become effective immediately and will expire on (Date). If no date is specified, this authorization will expire one (1) year from the signature date.

  • I may revoke this Authorization at any time, in a written revocation sent to the Custodian of Records. However, I understand that my health information might have already been released.

  • Information released by this Authorization might be re-disclosed by the recipient and might not be protected by state and federal privacy laws.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Address of Authority:

Patient Rights: As a patient you have the right to access, copy or inspect your protected health information (PHI) in accordance with federal law. You also have the right to request an amendment to your PHI, or request that we restrict the use and disclosure of it. These rights are further described in our Notice of Privacy Practices.

bottom of page