I request and authorize RedRiver Health and Wellness Center and/or RedRock Accident and Injury to release my healthcare information to:

I authorize the release of the following information:

I understand that the medical records released pursuant to this authorization could contain information concerning drug-related conditions, alcoholism, psychological conditions, psychiatric conditions, and/or blood-borne infectious disease which are subject to federal and/or state disclosure restrictions. By my signature below, I specifically authorize the disclosure of those records. I also understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations.

This permission to disclose my protected health information is valid for a period of ONE (1) YEAR, or until October 29, 2021, whichever occurs first. I understand that I can change my mind and cancel or revoke this permission at any time by sending a letter to RedRiver Health and Wellness Center/ RedRock Accident and Injury at the address given above. That revocation shall include all but the information which has already been disclosed or released pursuant to this authorization and prior receipt of the revocation, I hereby affirm that I have read and fully understand the statements above and consent to the disclosure of the protected health information for the purpose and extent stated.

Draw signature below.

Submit