Dr. Pamela K. Hannaman, M.S., N.D., C.P.C.

WA State Licensed, Board Certified Naturopathic Physician

Master of Science Biochemistry • Certified Professional (Medical) Coder

 

13074 Fairway Lane, Ashland, VA  23005 • H.Office (804) 798-4133 • FAX (804) 752-4935 • Cell (804) 350-4152    

 

Patient’s Full Name–––––––––––––––––––––––––––––––––––––––––––––Date–––––––––––––––––––––

Address–––––––––––––––––––––––––––––––––––––  City––––––––––––––State––––––Zip–––––––––––

Social Security Number––––––––––––––––––––––––– Date of Birth–––––––––––––––––––––––––––––––

Home Phone Number–––––––––––––––––––––––––––Other Phone–––––––––––––––––––––––––––––––

 

I,–––––––––––––––––––––––––––––––––––––, do hereby authorize Pamela Hannaman-Pittman N.D., M.S.

to obtain the following medical information:

––––Discharge Summary                    

––––History and Physical Exam                

––––Progress Notes                        

––––Operative Notes                        

––––Pathology Reports                    

––––ENTIRE CHART                        

 

Dates of Service: –––––––––––––––––––––––––––

 

––––I DO ––––I DO NOT authorize release of/permission to obtain information related to AIDS (Acquired Immunodeficiency Syndrome) or HIV (Human Immunodeficiency Virus) infection, Psychiatric care or Psychological assessment, and treatment for alcohol and/or drug abuse.

 

INFORMATION RELEASED FROM:

Name of Company/Agency/Facility/Person:–––––––––––––––––––––––––––––––––––––––––––––––––––

Complete Address––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

Purpose of Release of Medical Records:

––––Disability Determination                    

––––Referral to Specialist            

––––Insurance                        

––––Personal                            

––––Other_____________________________________________________________________________

 

I hereby authorize disclosure of the health information for the above named patient. This authorization is valid for (12) twelve months from the date of signature. I understand that I may cancel this request with written notification, but that it will not affect any information released prior to cancellation. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it and would then no longer be protected by federal HIPPA regulations. I understand that the health care provider, to whom this authorization is furnished, may not condition my treatment based upon whether or not I sign this authorization form.

 

–––––––––––––––––––––––––––––––––––––––––Signature of Patient or Guardian or Personal

                            Representative of Patient’s Estate

––––Laboratory Reports

––––Radiology Reports

––––EKG/Cardiac Testing Reports

––––Emergency Reports

––––Hospital Records

––––Other:––––––––––––––––––––––

––––Continuing Care

––––Legal Investigation

––––Worker’s Compensation

––––Change of Provider

Authorization For Release of/to Obtain Medical Information