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Call Us: (435) 688-7246 |
Fax Us: (435) 688-1363
301 N 200 E # 2A, St George, UT 84770
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Zion Pain Management | St. George, Utah
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About
Procedures
Back Pain
Patient Educational Material
FAQ
For Patients
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New Patient Information
Contact Us
Medical Release Form
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I authorize the release of my information
To Zion Pain Management
From Zion Pain Management
In addition to the general authorization to release records to the persons or entities listed above, I authorize the release of the records described as the following:
Release my information to/from
IHC
Physician
Patient
Attorney/Court Case
Other Authorization
Physician Name
Physician Address
Physician Fax
Communicable disease related information
Yes
No
including records of testing, diagnosis, or treatment of HIV, HIV related illness, AIDS, AIDS related diseases
Drug and alcohol treatment
Yes
No
Psychological or Psychiatric information
Yes
No
Pathology
Yes
No
slides, xrays, videotapes, photographs
Genetic screening
Yes
No
Information to be released
Entire Medical Record
Records of Visits
Statement of Charges/Payments
X-Ray, MRI, CT report(s)
Other
(Please check all that apply)
Records of Visits
Other Information
Confidential notice:The document accompanying this release contain confidential information belonging to the sender. This information is legally privileged and intended for the use of the individual named above, if you are not the intended recipient, please notify the sender and dispose of the information received. Use of this protected information by anyone other than the recipient is strictly prohibited. This request will expire 90 days from signature date.
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