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Completed forms may be emailed to [Info@Savrx.com](Info@Savrx.com) or mailed to 224 N. Park Ave Fremont, NE  \n68025.  \nI,   (Patient Name), hereby authorize Sav-Rx Prescription Services to release my confidential health information by providing a copy of my medical records to the recipient listed below. I understand this information may include complete records, care plans, treatment records, medication/prescription records, and other summary of care.  \nPatient Information:  \nPatient Name:   Date of Birth:    \nAddress:  \n___________________________________  \n___________________________________  \nI AUTHORIZE THE RELEASE OF MY PROTECTED HEALTH INFORMATION TO (Recipient):  \nName:    \nAddress:  \n_______________________________  \n_______________________________  \nPhone:    \nFax:    \nEmail:    \nPatient (or Legal Representative) Signature Signature Date  \nPrinted Name of Signer  \nIf Legal Representative, relationship to Patient","cbCaibT83oH7bMcJ","https://ap.wps.com/l/cbCaibT83oH7bMcJ","pdf",295992,"English","# Patient Authorization\n## Patient Information\n## Recipient Information\n## Signature and Date","[{\"question\":\"Who can use this form?\",\"answer\":\"Patients or a legal representative can complete and sign the form to authorize the release of medical records and protected health information.\"},{\"question\":\"What information may be released?\",\"answer\":\"The authorization may include complete records, care plans, treatment records, medication/prescription records, and other summaries of care.\"},{\"question\":\"How is the recipient identified?\",\"answer\":\"The recipient’s name, address, phone, fax, and email are provided in the designated section, and the patient (or legal representative) signs to authorize release to that recipient.\"}]","Authorization for Release of Medical Records - Form 2024 | PDF",1789633374]