fee Use Ony MRR SlestLuke's Bnd rar On psn Waa Cone TW 1 checked al. AUTHORIZATION TO ACCESS, USE, AND DISCLOSE PROTECTED HEALTH INFORMATION (PHI) Patint_Cocey Wi |/ams Date orbint: 24/20/1941 Address: / STASA STE city, AaralA Stato: TC) ze: £3¢6) Telephone numborts):con# (208) 60-782 Home e__ ‘Other names under which patient has been treated: Work # Release Information From: The folowing enttyndvidualis | Release Information To: The flowing entiyindviual i authorized to daclove my PH: authorized to access, use, and receive my PH Name: name_e. Bayo O. Crovmson Address: ___| Address: 875 S$ Vanguard Wey Su Te 20 Merdiay Ly $3642 Phone Fax Phone: (368) ¥233400 Fax, GR) 463-3356 If St. Luke's: () HospitalName:__ If St. Luke’s:7) HospitalName: Fr GCinic Name: Meivuive , breerhusT] D clinic Name: Purpose of Use and Disclosure: : Qlinsurance ~—C] Legal] Personal_—(Treatment/Continued Care L] Workers Compensation [J Schoo! C. Occupational Services: CL Employee Wellness DOther. ‘This request is valid for services for the followin elect one ofthe folowing options): 1D Approximate service date(s) 1D Alvisits between the dates_—Ju.w. 2008 and_Deese— CO Al visits between the date. and the expiration date of this form. Information fo be Used or Di [Biting information Lafmmunizations andlor Titers rativeProcedure Report Ex petkerge Summary [ita Pahotogy jomett Screening emergency Room Record Gitedication List substance Use Disorder istoryPhysicl CiEmploymenvOOT Physical ‘Drug anclor Alcohol Results Tein fr ogress Notes ined here jmaging Resorts) np ONLY 1 é cal Clearance Problem Lis Imaging Disc wireport (Mammo, Utrasound, Mental Health Evaluation/Studies: ‘Consultation Reports CT, MRI) Health Assessment Blotter: (Speci) = [ choose one format for receiving the information: Paper] Fax [= Electronic copy L] Other. | understand that the information in my health record may include information relating to acquired immunodeficiency ‘syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and genetic testing. Please note that psychotherapy notes require a separate authorization. | understand that ! have the right to revoke this authorization at any time except to the extent that action has been taken in reliance on this authorization. To revoke this authorization, | must submit a written revocation to Health Information ‘Management (Medical Records) at any St. Luke's health care facility, |understand that my health care cannot be conditioned on this authorization unless the purpose is solely to obtain and disclose information for a third party, such as an employer. | understand that information disclosed by St, Luke's pursuant to this authorization may be re-disclosed by the entity that receives this information and may no longer be protected by privacy regulations. : REEL 05/23/a) Wn Signati Date Time Relationship to the Patient (if applicable) THIS AUTHORIZATION WILL EXPIRE ONE (1) YEAR FROM DATE SIGNED. R103.020 SLHS_ og, 07/1002 rev. 06/14/18, 0/1620, 4/1521, Page tof 1