ANCZ01 Patient Authorization Form

PATIENT AUTHORIZATION
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
I authorize the Anchorage Radiation Therapy Center Staff to send and/or discuss my past, current, and future medical records to/with the following physicians and hospitals:
Referring

YesNo
Physician/Hospital
Authorization Revoked

MonthDayYear
Date
Primary Care

YesNo
Physician/Hospital
Authorization Revoked

MonthDayYear
Date
Surgeon

YesNo
Physician/Hospital
Authorization Revoked

MonthDayYear
Date
Medical Oncologist

YesNo
Physician/Hospital
Authorization Revoked

MonthDayYear
Date
Other

YesNo
Physician/Hospital
Authorization Revoked

MonthDayYear
Date
I authorize the following individual(s) to discuss and/or request my medical issues/records on my behalf:
Authorization Revoked

MonthDayYear
Date
BILLING RECORDS
I authorize the following named individuals to discuss my billing related information with the office and billing service staff:
Authorization Revoked

MonthDayYear
Date
I understand that I have the right to revoke authorizations assigned above at any point in time with the understanding that any records released or information communicated prior to this revocation were duly authorized.
Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty: