Authorization Form For Release Of Health Information Form - Planned Parenthood Of The St Louis Region & Southwest Missouri

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PLANNED PARENTHOOD OF THE ST LOUIS REGION & SOUTHWEST MISSOURI
AUTHORIZATION FORM FOR RELEASE OF HEALTH INFORMATION
PATIENT NAME:
__________________________________________________________________________________________
LAST
FIRST
MI
MAIDEN OR OTHER NAME
DATE OF BIRTH: _____-_____-_____
MEDICAL RECORD #: __________________________________
MO DAY
YR
ADDRESS: _____________________________________ CITY: ____________________________________
STATE: ________ ZIP: ____________ E-MAIL: ________________________________________________
DAY PHONE: ___________________________ CELL PHONE: _____________________________________
I REQUEST MY MEDICAL RECORD BE PROVIDED:
__ Paper (hard copy) or____ electronically by email: Email address______________________________
I HEREBY AUTHORIZE PLANNED PARENTHOOD OF THE ST. LOUIS REGION &
SOUTHWEST MISSOURI TO:
 RELEASE/SEND MY HEALTH INFORMATION TO THE FOLLOWING DOCTOR OR MEDICAL PROVIDER:
NAME:__________________________________________________________PHONE:______________________________
ADDRESS: ___________________________________________________CITY: ___________________________________
STATE: __________ ZIP: _______________ EMAIL__________________________________________________________
 REQUEST/RECEIVE MY HEALTH INFORMATION FROM THE FOLLOWING DOCTOR OR MEDICAL
PROVIDER:
NAME:__________________________________________________________PHONE:______________________________
ADDRESS:___________________________________________________CITY: ___________________________________
STATE: __________ ZIP: _______________ EMAIL__________________________________________________________
SEND TO: Planned Parenthood of the St. Louis Region and Southwest Missouri
Central West End Health Center
North County Health Center
4251 Forest Park Ave
2796-98 North Highway 67
St. Louis, MO 63108
St. Louis, MO 63033
314-531-7526
314-921-4445
F: 314-533-1586
F: 314-921-5165
South Grand Health Center
Fairview Heights Health Center
3401 South Grand
Lake Land Square
St. Louis, MO 63118
4529 North Illinois
314-865-1850
Belleville, IL 62226
F: 314-865-0535
618-277-6668
F: 618-234-5230
West County Health Center
Springfield Health Center
#1 Stonegate Center
Manchester, MO 63088
626 East Battlefield
636-431-0030
Springfield, MO 65807
F: 636-431-0035
417-883-3800
F: 417-883-3994
St. Peters Health Center
208 Mid Rivers Mall Center
Joplin Health Center
St. Peters, MO 63376
710 Illinois Ave
636-279-3339F: 636-279-2236
Joplin, MO 64801
417-781-6500
F: 417-781-3660
Z:\FORMS\RE19p_Release and RequestAutorizationForm_2014_07_10.doc

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