Medford Release Form

To release a copy of medical information to:
(Southern Oregon Alternative Medicine)
836 East Main St. #3 Medford, OR 97504
Office: 541-779-5235 Fax: 541-779-0479
The information will be used on my behalf for the following purpose(s): Alternative Therapy

By initialing the space below, I specifically authorize the release of the following medical records, if such records exist:

If we are requesting this Authorization from you for our own use and disclosure, or to allow another health care provider or health plan to disclose information to us:
 1. We cannot condition our provision or services or treatment to you on the receipt of this signed authorization;
 2. You may inspect a copy it the protected health information to be used or disclosed;
 3. You may refuse to sign this Authorization; and
 4. We must provide you with a copy of the signed authorization

You have the right to revoke the Authorization at any time, provided that you do so in writing and except to the extent that we have already used or disclosed the information in reliance on this Authorization.
Unless revoked earlier or otherwise indicated, this Authorization will expire 180 days from the date of signing or shall remain in effect for the period reasonable needed to complete the request.

I have reviewed and I understand this Authorization, I also understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer be protected under federal law.

• Date Faxed:
• Date of Appt:
• Chart Notes Received:
• NEW OR RENEW_________