Release of Information
This form is only intended for requesting Fordland Clinic retrieve medical records from other clinics, hospitals, etc. If you need to request your medical records from Fordland Clinic, please do so through Healthmark.
Covering the Periods of Health Care
As an FQHC, we are required to gather and report on Screening and Prevention.
Please fax above requested information to 417-767-4054
I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.
I certify that this request has been made freely, voluntarily and without coercion and that the information given above is accurate and complete to the best of my knowledge. My treatment, payment, enrollment or eligibility is not conditioned upon signing this authorization.
I understand that I may revoke or terminate this authorization by submitting a written revocation to Fordland Clinic, Inc. Unless revoked, this authorization is effective through ___/___/___, or one year from date of signature, unless otherwise specified.
I understand that information that is disclosed under this authorization may be disclosed again by the person or organization to which it is sent and that the privacy of this information may not be protected under the federal privacy regulations.
By selecting the 'I agree' button, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By selecting 'I agree' using any device, means, or action, I consent to the legally binding terms and conditions of this document. I further agree that my signature on this document is as valid as if I signed the document in writing. I am also confirming that I am authorized to enter into this Agreement. If I am signing this document on behalf of a minor, I represent and warrant that I am the minor?s parent or legal guardian. *I may decline to electronically sign this document and withdraw my consent to sign this document electronically by contacting Fordland Clinic directly, which may delay transactions. I understand that I have the option to request to sign this document on paper or to receive a paper copy of the signed document.
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