ࡱ> :<9b jbjb ,& H H!   , R    &: L   I.d  0! l , HHHH  Asheville Pulmonary & Critical Care Associates, P.A. Use and Disclosure of Medical Records Patient Name: ______________________________________________________________________ Date of Birth: _____________________________________ Patient Chart: _____________________________________ Date of request for access: __________________________ Choose one of the following: [ ] I authorize Asheville Pulmonary & Critical Care Associates, P.A. to send my medical record to: ______________________________________________________________________________________________ Description of information to be released (office notes, hospital notes, lab / test results, etc.): ______________________________________________________________________________________________ The purpose of this authorization to release information is: ______________________________________________ [ ] I authorize Asheville Pulmonary & Critical Care Associates, P.A. to obtain my medical record from: ______________________________________________________________________________________________________________________________________________________________________________________________ Description of information to be released (office notes, hospital notes, lab / test results, etc.): ______________________________________________________________________________________________ The purpose of this authorization to release information is: ______________________________________________ I understand that: This authorization includes, but not limited to, consent for the release of alcohol, drug, psychiatric and psychological information, cancer testing, cancer results and information relating to HIV testing, AIDS and AIDS-related syndromes. The information disclosed may no longer be protected by the federal privacy law and may be re-disclosed by the recipient. My decision to sign or not to sign this authorization will not affect the treatment provided to me by Asheville Pulmonary & Critical Care Associates, P.A. I have the right to revoke this authorization at any time before use or disclosure of the information. Written notice is required to revoke this authorization and can be mailed or faxed to the attention of the Privacy Official of Asheville Pulmonary & Critical Care Associates, P.A. All revocations are not effective until received by the Privacy Official. A copy or fax of this authorization shall be valid as this original. _________________________________________________________________ Signature of Patient or Authorized Person (Documentation of authority required): __________________________________________________________________ Witness: ___________________________________ Date:      3}~2PY~~~w hhhh5h h{h hh{h{h{56 h{56h{ hhhhh5 h5 h I!CJh{h5CJh5CJmHnHu!jhY.5CJUmHnHuhY.5CJmHnHuN/d|?  7    ~ ~gd & Fgddhgdgd2'Ygd".gdgd *1hP:pY./ =!`"`#$%H Ddde  bA?Picture 1logo-Stone.png"b` WQڥ %u< Dn4 WQڥ %uPNG  IHDRdeFsRGBgAMA a cHRMz&u0`:pQ<tEXtSoftwareAdobe ImageReadyqe<|IDATx^]&E]G|G45L#l#a5MH  qze9=o=˻G: dMr 9y85dkHO3l 5dZ لl S?lB6!ۜm~2-uB껻O?|z3 *1+X֫n ItT{댮|M+2(YB*rHg8!Z7+!Ւ`oLÚkoyGѤ#Azgxk\By? |uגx%/EOX#7_': &$le{\MOgw4#s.ȀhR}=קq 8MN:B]`ZۻВH̱$.\q z/HvrU! YͪQLl&Aan8چ1Ddh_x2_%_NRVDKb9qK t$vV?[g{{|*Īr^B4w~ҎG:GHZZqz$w%;; kgu7uGM^sA=֧02Za[2W.sYJ5d0-P'^o}ӄ}-DB;)L^!8Gw#1)Njc}bDZ@ufػ>5rH~