Please answer all questions, then click 'Submit' below to complete:

AUTHORIZATION TO RELEASE MEDICAL RECORDS

Patient Name: *

Date of Birth: * +

Address: *

City, State, Zip: *

Last 4 of SSN: *

Phone (xxx) xxx-xxxx: *

Email address: *

RELEASE FROM (check all that apply): *

Monarch (all locations, EXCEPT those listed below)

DWI Program or MAT Program

Tanglewood Arbor

Other (Specify) Other (Specify)

RELEASE TO (Please fill out all items below):

Name of Individual: *

Name of Organization: *

Street Address or P.O. Box: *

City, State, Zip: *

Fax:

Email:

REASON FOR RELEASE (check all that apply): *

DATES OF RECORDS TO RELEASE (Check one): *

All Dates

Select Dates

From: +

To: +

WHAT TO RELEASE (check all that apply): *

DELIVERY METHOD (check all that apply; charges may apply): *

U.S. Mail

Encrypted E-mail (this may require setting up an account)

Fax

Other (Specify) Other (Specify)

I understand that:
- I can cancel this authorization at any time. I must cancel in writing and send or deliver the cancellation to Monarch. Any cancellation will apply only to information not yet released by Monarch.

- This is a full release, including information related to behavioral/mental health, drug and alcohol abuse treatment (in compliance with 42 CFR Part 2), genetic information, HIV/AIDS, and other sexually transmitted diseases.

- Once my health information is released, the recipient may disclose or share my information with others and my information may no longer be protected by federal and state privacy protections.

- Monarch may not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization.

- A fee may be charged for providing the protected health information.

- I have a right to receive a copy of this form, upon request.

This permission expires one year after the date of my signature, unless another date or event is written here: (Please leave blank unless there is a reason for this permission to expire sooner than one year). +