Authorization to Release Medical Information
The Adams County Communications Center (ADCOM) to release the following records, including any Protected Health Information regarding the patient that the records contain
OPTIONAL Authorization to Transmit via Electronic Means: I request that the records listed above be released to the recipient by fax or email, and not by U.S. mail or delivery service. I understand the records will be sent through unencrypted fax/email that is not secure and there is a risk that the records could be seen by a third party during electronic transmission, while in electronic storage, and/or upon completed delivery. ADCOM is not responsible for unauthorized access of the Protected Health Information resulting from the faxed or emailed transmission, or for safeguarding the Protected Health Information upon delivery.
Signature of Patient or Personal Representative