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SSM Health “Request for Access to/Authorization for Use and Disclosure of Protected Health Information” Name of SSM Health Entity maintaining the information that is subject to this Authorization: PATIENT NAME: LAST FIRST MI Maiden or Other Name DATE OF BIRTH:-- FORMER NAME: MEDICAL RECORD MO DAY YR ADDRESS: CITY:STATE:ZIP: DAY PHONE: EVENING PHONE: Type of access requested: Inspection Hard Copy Electronic Copy (only available if SSM Health maintains the requested information electronically) To Disclose My Protected Health Information To: I Hereby Authorize: NAME ADDRESS CITY, STATE ZIP PHONE FAX NAME Relationship ADDRESS CITY, STATE ZIP PHONE FAX METHOD OF DELIVERY OF RECORDS (please select one): Mail Hold for pick up by: Electronic (records will be provided on a CD and mailed to your residence) INFORMATION TO BE RELEASED: DATES: I specifically authorize the release of information relating to: Discharge Summary Substance abuse (including alcohol/drug abuse) History Physical Exam Progress Notes Mental health or behavioral health Lab Reports HIV related information (AIDS related testing) X-Ray Reports X Medication Records SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE DATE Detailed Bill Other (specify content and dates): PURPOSE OF DISCLOSURE: Changing physicians Consultation Insurance/Workers’
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