Zip
(or legally authorized)
Patient Limits the Release of the Following Information:
Street City/State
Last Name First Name
Address:
Name:
Section III - Release The undersigned authorizes the City of Rio Rancho to release any and all
medical records of treatment by the City of Rio Rancho to:
Patient Signature:
Witnessed By:
Phone #: Fax #:
By signing this authorization, I understand the following conditions apply: (1) I have the right to revoke this
authorization by providing a written notice of revocation to the City of Rio Rancho – Department of Financial
Services/Ambulance Billing. The revocation will not apply to information that has already been released prior to the
receipt of the written revocation. The revocation will not apply to my insurance company when the law provides my
insurer with the right to contest a claim. (2) The City of Rio Rancho will not condition treatment on whether I sign this
authorization. (3) I have a right to inspect and receive a copy of the material to be disclosed. The information used or
disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and may no longer be protected
by federal privacy rules. (4) Authorizing the disclosure of this health information is voluntary and I may refuse to sign
the authorization. (5) I have the right to request a copy of this authorization. (6) A copy of this authorization is as valid
as the original.
E-Mail:
Please return this completed and signed form to: Attn: Steve Perkins, Ambulance Billing, 3200
Civic Center Circle NE, Rio Rancho, NM 87144 - or fax to: (505) 891-5762
Date
Date
Section II - Information to be Released
MI
Medical Records From (date):
Reason for Release of Records:
Company:
To (date):
City of Rio Rancho
Department of Financial Services - Ambulance Billing
Authorization for Release of Medical Records
Please complete all the information on this form as completely and accurately as possible by typing or using
blue or black ink. Please contact us at (505) 891-5021 with any questions.
Last Name First Name
Section I - Patient Information
Patient Name: SSN:
Date of Birth:
v10.9.20
click to sign
signature
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