Records Request Form Name(Required) First Last Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Disclosure(Required) I hereby authorize the following practice/physician to make disclosures of my protected health information as indicated below. I also authorize communication between the person, provider or facility indicated below to provide continuity of care. Name of Person/Provider :(Required) First Name of Medical Facility/Institution:(Required) First Phone(Required)Fax Information to be disclosed:(Required) Hospital Records Medical Records Lab Reports Pathology Reports Clinician Chart Notes Physical Therapy Records Emergengy/Urgent Care Records Diagnostic Imaging Reports (X-ray,MRI, CT, Pet, U/S) Other HiddenThis Information is to be disclosed to:(Required) Dr. Lisa Dickinson, ND Dr. Meghan Bennett, ND Dr. Soledad Diaz, ND This Information is to be disclosed and sent to: Amber Wellness Group 1944 NE 45th Ave Portland, OR 97213 Phone: 971.319.0045 Fax: 833-962-2422 If you have any lab or imaging records from the previous year from another provider, please fill out the Release of Record Form. You can either submit to the outside provider yourself or email the completed form to us and we will coordinate for you.initialing here(Required) 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. Consent(Required) I understand the following:(Required)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 pressureThis consent is specifically for the information created from service provided on or before the date of my signatureSignature(Required)Date(Required) MM slash DD slash YYYY CAPTCHA
