On Our Own of Frederick County (OOOFC) Release of Information
Request for the Use and Disclosure of Protected Health Information
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Email *
I, (Name) hereby voluntarily authorize the disclosure of my personally identifiable information related to my health, wellness, and recovery to On Our Own of Frederick County (OOOFC) and (enter name of facility you are authorizing OOOFC to communicate with below). *
Full Name *
Date of Birth (MM/DD/YYY) *
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Last 4 of Social Security Number *
I authorize the organization/facility/doctor listed below to release my information and/or medical records to: On Our Own of Frederick County located at 22 S. Market Street  Frederick, MD 21701. *
The purpose of this disclosure is: *
Required
The information to be disclosed includes: *
The information to be disclosed includes: *
I agree and understand to the terms of this Consent for Release of Information.
I am the individual, to whom the requested information or record(s) applies. I declare under penalty of perjury that I have examined the information on this form and it is true and correct to the best of my knowledge. I understand that anyone who knowingly or willfully seeking or obtaining access to records about another person under false pretenses is punishable by the law.


I understand that I may revoke this authorization in writing submitted at any time to OOOFC, except to the extent that action has been taken in reliance on this authorization. If this authorization was obtained as a condition of obtaining insurance coverage or a policy of insurance, other law may provide the insurer with the right to contest a claim under the policy. If this authorization has not been revoked, it will terminate one year from the date of my signature unless a different expiration date or expiration event is stated.
(e)Signature/digital signature of Individual or Authorized Representative (state relationship to individual). *
Please select the date this release is authorized. *
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eSigned by Dr. L.A. McCrae of On Our Own of Frederick County
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