Authorization to Disclose Medical Information
	TO:  _____________________________________      _____________________________________      _____________________________________                                (service provider) Patient ___________________________ Date of Birth  ______________________ SSN _____________________________ I authorize release and disclosure of information (written or verbal) regarding my medical records and associated billing to:                                 Nursing Assessments (Taresa Nantt RNC) for the purposes of reviewing, auditing, and evaluating associated charges for the following dates of service:                       ___________________________________________________________ Authorization and release of records to include: [  ]  Medical Record (complete record including nurse notes, progress notes, physician orders,    lab/radiology results, and all dictation [  ]  Detailed Billing (line item) [  ]  Other ___________________________________________________________ This authorization shall remain in effect for a period of six months from the date of signature below or completion of audit, whichever is longer.  A photocopy of this authorization shall be considered as effective and valid as the original authorization. Date___________________        Patient/Designee  ____________________________________ Records may be mailed or faxed to the following Nursing Assessments 20 W Turner Rd Ste C PMB 14 Lodi CA  95240 Fax (209) 333-6221