Dr. Gil's Clinic

Gil Mobley, MD
Dr. Gil's Clinic
33530 First Way South
Suite 102
Federal Way, Washington 98003
(206)330-2215

Dr. Gil's Clinic — MMJ assessment

This facsimile and any attachments are intended only for the use of the addressee and may contain information that is privileged and confidential. If you are not the intended recipient or an authorized representative of the intended recipient do not review, disseminate, and distribute the facsimile or attachments. You are hereby notified that any dissemination of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone at (206)330-2215 and destroy the facsimile and any attachments or return them to us at 33530 1st Way S. Suite 102, Federal Way, WA 98003. Thank you for your cooperation.

Authorization for Use or Disclosure of Protected Health Information

Patient Name: _____________________________________: Maiden or Other Name: _______________________
Social Security: _______-______-_________ Date of Birth: __________________________
Address: ____________________________________________ Home/Cell Phone: ________________________________

I authorize _______________________________ to provide a copy, summary, or narrative of my medical records (as indicated by the check mark(s) below) or to otherwise release confidential information. At this time I am requesting the following:
__________ Complete record (History & Physical Exam, Lab Report, X-Ray Report, Consultation Report)
__________ Records of care from _____________________ to ________________ only
__________ Records of care concerning the following condition(s)
__________ Other; Specify: __________________________________________________ ____
I understand that copies of the records indicated will be communicated to:
Dr. Gilā??s Immediate Care
33530 1st Way S. Suite 102, Federal Way, WA 98003
Fax: (253)237-0701 Telephone: (206)330-2215
PURPOSE OF DISCLOSURE: CONTINUING CARE
I understand that you will provide this information within 15 business days from receipt of request.
I understand that this authorization will expire in 12 months from the date thereof unless otherwise specified. A photo copy will be considered as valid as the original.
I UNDERSTAND THAT MY TREATMENT MAY NOT BE CONDITIONED ON MY COMPLETION OF THIS AUTHORIZATION FORM EXCEPT WHEN THE PROVISON OF HEALTH CARE IS SOLEY FOR THE PURPOSE OF CREATING PROTECTED HEALTH INFORMATION FOR DISCLOSURE TO A THIRD PARTY.
1. Purpose. As a patient,, I authorize Dr. Gilā??s Immediate Care to use and disclose my individual health information for the purpose of conducting the research for medical records.
2. Individual Health Information to be Used or Disclosed. My individual health information that may be used or disclosed to conduct this research includes: Substance Abuse, Mental Health, Psychotherapy notes and HIV related information from hospitals, clinics, health care providers, and health plans that provide my health care during the treatment.
3. Parties Who May Receive or Use My Individual Health Information. The individual health information disclosed by parties listed in item 3 and information disclosed by me during the course of the research may be received and used by Dr Gilā??s Immediate Care.
4. Right to Refuse to Sign This Authorization. I do not have to sign this Authorization. If I decide not to sign the Authorization, I may not be allowed to participate in this treatment. However, my decision not to sign this Authorization will not affect any other treatment, payment, or relationship with the Dr. Gilā??s Immediate Care.
5. Right to Revoke. I can change my mind and withdraw this Authorization at any time by sending a written notice to inform my decision. If I withdraw this Authorization, the researcher may only use and disclose the protected health information already collected for this treatment. No further health information about me will be collected by or disclosed to Dr. Gilā??s Immediate Care.
Signed: ___________________________________ Date: ________________
(Patient or person legally authorized to consent on patients behalf)
jamessr Reviewed by jamessr on . Professional Medical Marijuana Assessment in Washington State Dr. Gil's Clinic Gil Mobley, MD Dr. Gil's Clinic 33530 First Way South Suite 102 Federal Way, Washington 98003 (206)330-2215 Dr. Gil's Clinic — MMJ assessment Rating: 5