ANCZ01 Patient Authorization Form

Heads up: This form includes fields managed by your provider (marked with 🔒). Some appear empty — if you were expecting these to be pre-filled, please contact your provider for an updated form link.

PATIENT AUTHORIZATION

Patient Name *

First Name

Middle Name

Last Name

Date of Birth *

📅

Date

I authorize the Anchorage Radiation Therapy Center Staff to send and/or discuss my past, current, and future medical records to/with the following physicians and hospitals:

Referring

Yes

Physician/Hospital

Authorization Revoked

📅

Date

Primary Care

Yes

Physician/Hospital

Authorization Revoked

📅

Date

Surgeon

Yes

Physician/Hospital

Authorization Revoked

📅

Date

Medical Oncologist

Yes

Physician/Hospital

Authorization Revoked

📅

Date

Other

Yes

Physician/Hospital

Authorization Revoked

📅

Date

I authorize the following individual(s) to discuss and/or request my medical issues/records on my behalf:

Authorization Revoked

📅

Date

BILLING RECORDS

I authorize the following named individuals to discuss my billing related information with the office and billing service staff:

Authorization Revoked

📅

Date

I understand that I have the right to revoke authorizations assigned above at any point in time with the understanding that any records released or information communicated prior to this revocation were duly authorized.

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature *

Date

📅

Date

HIPAACOMPLIANCE

Please complete the required fields

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