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Authorization to Release Patient Information

The electronic form below may be used by a patient or legal representative to authorize the disclosure of the patient's information. 

As a patient of Blanchard Valley Health System, most health records can also be accessed by logging into the BVHS MyHealth patient portal.

Patient full name:  *Maiden name: Mailing address:  *City:  *State:  *Date of birth:  *Phone number:  *Email address: Social security number (last four digits only):  *1. I hereby authorize the use or disclosure of protected health information about the above individual as described below. 2. Blanchard Valley Health System may use or disclose the information to: If the person receiving the information is the patient, proceed to Section 3 

Recipient name: Mailing address (include street, city, state and zip code) Phone number: Fax number: Email address: 3. The purpose of the authorized use or disclosure of the information is as follows: Check all that apply 






Please specify OTHER: 4. Date of service to be disclosed or used FROM:  *Date of service to be disclosed or used THROUGH:  *5. Records to be disclosed or used: 











Please specify OTHER: ** According to Blanchard Valley Health System Notice of Privacy Practices and Designated Record Set 6. This authorization will remain valid for one year from today’s date or: 
Select date if you checked the above box: If you selected the authorization should end at the end of the research study, this is applicable only if the authorization is for a research study or for creation and maintenance of a research database or research repository. Consent  *7. The information requested should be disclosed: 







Electronic signature of patient or legal representative Name of Person Completing/Signing Form  *Complete this final section if you are NOT the patient. If you are the patient, proceed to "SUBMIT" If you are the legal representative of the patient, describe the scope of your authority. 



Upload documentation supporting your legal representation of the patient