Release of Records Form This form is for requesting Amber Wellness Group to send records to another provider/facility. Patient Name(Required) Email(Required) Date of Birth(Required) MM slash DD slash YYYY I authorize the following practice/physician to disclose my protected health information as indicated below. I also authorize communication between the person, provider or facility indicated below to provide continuity of care. This Information is to be disclosed from: Amber Wellness Group 1944 NE 45th Ave Portland, OR 97213 Phone: 971.319.0045 Fax: 833-962-2422Information to be disclosed:(Required) Medical Records Clinician Chart Notes Lab Results Emergency/Urgent Care Records Pathology Reports Imaging Reports (X-ray,MRI, CT, Pet, U/S) Billing Information Dates of information to be disclosed:From Date MM slash DD slash YYYY To Date MM slash DD slash YYYY Entire Health Record? Yes No Please send my records to the following:Name of Person/Provider:(Required) Name of Medical Facility/Institution:(Required) PhoneFax Consent(Required) By initialing here, I understand that the information in my health records may include information indicating the presence of a communicable or venereal disease which may include, but is not limited to, hepatitis, syphilis, gonorrhea, HIV and AIDS. The records may also include information about behavioral and/or mental health services and/or treatments for alcohol and/or drug abuse.I understand the following: - I may revoke this authorization at any time by providing written notice to Amber Wellness Group - I may not be able to revoke authorization if our practice has already taken action utilizing the authorization or if it was obtained as a condition of obtaining insurance coverage. - Amber Wellness Group will not condition treatment or payment based on my signing this authorization - I am signing this authorization freely without pressureSignature(Required)Date(Required) MM slash DD slash YYYY
