{"id":122684,"date":"2022-08-26T00:19:59","date_gmt":"2022-08-26T00:19:59","guid":{"rendered":"https:\/\/pine-rest-forms-v2.local\/?page_id=122684"},"modified":"2024-01-10T11:42:14","modified_gmt":"2024-01-10T16:42:14","slug":"authorization-release-medical-info-records-michigan","status":"publish","type":"telehealth","link":"https:\/\/forms.pinerest.org\/telehealth\/authorization-release-medical-info-records-michigan\/","title":{"rendered":"Authorization for release and disclosure, and\/or request for medical information and records &#8211; MICHIGAN"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"122684\" class=\"elementor elementor-122684\" data-elementor-post-type=\"telehealth\">\n\t\t\t\t<div class=\"elementor-element elementor-element-290b9a2 e-flex e-con-boxed space--default space--none space--none space--none atlas-size-default color-mode--default pr-container-bg pr-container-bg--default atlas-elevation atlas-elevation--default e-con e-parent\" data-id=\"290b9a2\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-1009052 elementor-widget elementor-widget-atlas-dual-heading\" data-id=\"1009052\" data-element_type=\"widget\" data-widget_type=\"atlas-dual-heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t<h2 class=\"atlas-heading atlas-heading--dual atlas-heading--border atlas-size-default\">\n\t\t\t\t<span class=\"atlas-heading__title\">Release<\/span>\n\t\t\t\t<span class=\"atlas-heading__title2\">Of Information<\/span>\n\t\t\t<\/h2>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-5c25d07 atlas-gf-ajax-true elementor-widget elementor-widget-atlas-gravity-forms\" data-id=\"5c25d07\" data-element_type=\"widget\" data-widget_type=\"atlas-gravity-forms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t        <div class=\"atlas-gf-form elementor-clickable\">\n            \n                <div class='gf_browser_unknown gform_wrapper gform-theme gform-theme--foundation gform-theme--framework gform-theme--orbital' data-form-theme='orbital' data-form-index='1' id='gform_wrapper_54' style='display:none'><style>#gform_wrapper_54[data-form-index=\"1\"].gform-theme,[data-parent-form=\"54_1\"]{--gf-color-primary: #204ce5;--gf-color-primary-rgb: 32, 76, 229;--gf-color-primary-contrast: #fff;--gf-color-primary-contrast-rgb: 255, 255, 255;--gf-color-primary-darker: #001AB3;--gf-color-primary-lighter: #527EFF;--gf-color-secondary: #fff;--gf-color-secondary-rgb: 255, 255, 255;--gf-color-secondary-contrast: #112337;--gf-color-secondary-contrast-rgb: 17, 35, 55;--gf-color-secondary-darker: #F5F5F5;--gf-color-secondary-lighter: #FFFFFF;--gf-color-out-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-out-ctrl-light-rgb: 17, 35, 55;--gf-color-out-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-out-ctrl-light-lighter: #F5F5F5;--gf-color-out-ctrl-dark: #585e6a;--gf-color-out-ctrl-dark-rgb: 88, 94, 106;--gf-color-out-ctrl-dark-darker: #112337;--gf-color-out-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-color-in-ctrl: #fff;--gf-color-in-ctrl-rgb: 255, 255, 255;--gf-color-in-ctrl-contrast: #112337;--gf-color-in-ctrl-contrast-rgb: 17, 35, 55;--gf-color-in-ctrl-darker: #F5F5F5;--gf-color-in-ctrl-lighter: #FFFFFF;--gf-color-in-ctrl-primary: #204ce5;--gf-color-in-ctrl-primary-rgb: 32, 76, 229;--gf-color-in-ctrl-primary-contrast: #fff;--gf-color-in-ctrl-primary-contrast-rgb: 255, 255, 255;--gf-color-in-ctrl-primary-darker: #001AB3;--gf-color-in-ctrl-primary-lighter: #527EFF;--gf-color-in-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-in-ctrl-light-rgb: 17, 35, 55;--gf-color-in-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-in-ctrl-light-lighter: #F5F5F5;--gf-color-in-ctrl-dark: #585e6a;--gf-color-in-ctrl-dark-rgb: 88, 94, 106;--gf-color-in-ctrl-dark-darker: #112337;--gf-color-in-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-radius: 3px;--gf-font-size-secondary: 14px;--gf-font-size-tertiary: 13px;--gf-icon-ctrl-number: url(\"data:image\/svg+xml,%3Csvg width='8' height='14' viewBox='0 0 8 14' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M4 0C4.26522 5.96046e-08 4.51957 0.105357 4.70711 0.292893L7.70711 3.29289C8.09763 3.68342 8.09763 4.31658 7.70711 4.70711C7.31658 5.09763 6.68342 5.09763 6.29289 4.70711L4 2.41421L1.70711 4.70711C1.31658 5.09763 0.683417 5.09763 0.292893 4.70711C-0.0976311 4.31658 -0.097631 3.68342 0.292893 3.29289L3.29289 0.292893C3.48043 0.105357 3.73478 0 4 0ZM0.292893 9.29289C0.683417 8.90237 1.31658 8.90237 1.70711 9.29289L4 11.5858L6.29289 9.29289C6.68342 8.90237 7.31658 8.90237 7.70711 9.29289C8.09763 9.68342 8.09763 10.3166 7.70711 10.7071L4.70711 13.7071C4.31658 14.0976 3.68342 14.0976 3.29289 13.7071L0.292893 10.7071C-0.0976311 10.3166 -0.0976311 9.68342 0.292893 9.29289Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-select: url(\"data:image\/svg+xml,%3Csvg width='10' height='6' viewBox='0 0 10 6' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M0.292893 0.292893C0.683417 -0.097631 1.31658 -0.097631 1.70711 0.292893L5 3.58579L8.29289 0.292893C8.68342 -0.0976311 9.31658 -0.0976311 9.70711 0.292893C10.0976 0.683417 10.0976 1.31658 9.70711 1.70711L5.70711 5.70711C5.31658 6.09763 4.68342 6.09763 4.29289 5.70711L0.292893 1.70711C-0.0976311 1.31658 -0.0976311 0.683418 0.292893 0.292893Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-search: url(\"data:image\/svg+xml,%3Csvg version='1.1' xmlns='http:\/\/www.w3.org\/2000\/svg' width='640' height='640'%3E%3Cpath d='M256 128c-70.692 0-128 57.308-128 128 0 70.691 57.308 128 128 128 70.691 0 128-57.309 128-128 0-70.692-57.309-128-128-128zM64 256c0-106.039 85.961-192 192-192s192 85.961 192 192c0 41.466-13.146 79.863-35.498 111.248l154.125 154.125c12.496 12.496 12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-label-space-y-secondary: var(--gf-label-space-y-md-secondary);--gf-ctrl-border-color: #686e77;--gf-ctrl-size: var(--gf-ctrl-size-md);--gf-ctrl-label-color-primary: #112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_54'  action='\/wp-json\/wp\/v2\/telehealth\/122684' data-formid='54' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_54' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_54_48\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_48\" ><font size=\"4\">Please note that you may be contacted by the Health Information Management (HIM) Department to verify or clarify information in this online release of information.<\/font><\/div><fieldset id=\"field_54_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_30\" ><legend class='gfield_label gform-field-label' >Do you want medical information and records sent or received?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_54_30'>\n\t\t\t<div class='gchoice gchoice_54_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Yes'  id='choice_54_30_0' onchange='gformToggleRadioOther( this )'  tabindex='1'  \/>\n\t\t\t\t\t<label for='choice_54_30_0' id='label_54_30_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_54_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='No'  id='choice_54_30_1' onchange='gformToggleRadioOther( this )'  tabindex='2'  \/>\n\t\t\t\t\t<label for='choice_54_30_1' id='label_54_30_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_54_22\" class=\"gfield gfield--type-name gfield--input-type-name col-xs-24 col-sm-16 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_22\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Patient Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_54_22'>\n                            \n                            <span id='input_54_22_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_22.3' id='input_54_22_3' value='' tabindex='4'  aria-required='true'     \/>\n                                                    <label for='input_54_22_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_54_22_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_22.6' id='input_54_22_6' value='' tabindex='6'  aria-required='true'     \/>\n                                                    <label for='input_54_22_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_54_4\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown col-xs-24 col-sm-8 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_4\" ><legend class='gfield_label gform-field-label' >Patient Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_54_4' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_54_4_1_container'><select name='input_4[]' id='input_54_4_1' tabindex='8'  aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_54_4_2_container'><select name='input_4[]' id='input_54_4_2' tabindex='9'  aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_54_4_3_container'><select name='input_4[]' id='input_54_4_3' tabindex='10'  aria-required='true'  ><option value=''>Year<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><div id=\"field_54_46\" class=\"gfield gfield--type-phone gfield--input-type-phone clear-floats gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_46\" ><label class='gfield_label gform-field-label' for='input_54_46'>Patient Phone #<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_54_46'>This patient contact phone number will be used in the event we have questions about this release or a records request.<\/div><div class='ginput_container ginput_container_phone'><input name='input_46' id='input_54_46' type='tel' value='' class='small' tabindex='11'  aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_54_46\"  \/><\/div><\/div><fieldset id=\"field_54_47\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_47\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Patient Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_54_47'>This patient contact address will be used in the event we have questions about this release or a records request and we can't reach you by phone or if you request that a copy of this release be mailed to you.<\/div>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_54_47' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_54_47_1_container' >\n                                        <input type='text' name='input_47.1' id='input_54_47_1' value='' tabindex='12'   aria-required='true'    \/>\n                                        <label for='input_54_47_1' id='input_54_47_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_54_47_2_container' >\n                                        <input type='text' name='input_47.2' id='input_54_47_2' value='' tabindex='13'    aria-required='false'   \/>\n                                        <label for='input_54_47_2' id='input_54_47_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_54_47_3_container' >\n                                    <input type='text' name='input_47.3' id='input_54_47_3' value='' tabindex='14'   aria-required='true'    \/>\n                                    <label for='input_54_47_3' id='input_54_47_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_54_47_4_container' >\n                                        <input type='text' name='input_47.4' id='input_54_47_4' value='' tabindex='16'     aria-required='true'    \/>\n                                        <label for='input_54_47_4' id='input_54_47_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_54_47_5_container' >\n                                    <input type='text' name='input_47.5' id='input_54_47_5' value='' tabindex='17'   aria-required='true'    \/>\n                                    <label for='input_54_47_5' id='input_54_47_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_47.6' id='input_54_47_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_54_34\" class=\"gfield gfield--type-email gfield--input-type-email same-email clear-floats field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_34\" ><label class='gfield_label gform-field-label' for='input_54_34'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_34' id='input_54_34' type='email' value='' class='medium' tabindex='18'    aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_54_49\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_49\" ><label class='gfield_label gform-field-label' for='input_54_49'>Form Completed By<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_49' id='input_54_49' class='medium gfield_select' tabindex='19'   aria-required=\"true\" aria-invalid=\"false\" ><option value='Self' >Self<\/option><option value='Parent' >Parent<\/option><option value='Guardian' >Guardian<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_54_23\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_23\" ><label class='gfield_label gform-field-label' for='input_54_23'>If Other, please describe relationship to patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_54_23' type='text' value='' class='medium'   tabindex='20'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_54_21\" class=\"gfield gfield--type-name gfield--input-type-name clear-floats gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_21\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name of person completing the release, if not the patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_54_21'>\n                            \n                            <span id='input_54_21_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_21.3' id='input_54_21_3' value='' tabindex='22'  aria-required='true'     \/>\n                                                    <label for='input_54_21_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_54_21_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_21.6' id='input_54_21_6' value='' tabindex='24'  aria-required='true'     \/>\n                                                    <label for='input_54_21_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_54_6\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_6\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I authorize Pine Rest Christian Mental Health Services to:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_54_6'>(must choose one or both from the list below)<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_54_6'><div class='gchoice gchoice_54_6_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.1' type='checkbox'  value='Yes release'  id='choice_54_6_1' tabindex='26'  aria-describedby=\"gfield_description_54_6\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_54_6_1' id='label_54_6_1' class='gform-field-label gform-field-label--type-inline'>release information from my medical records to the individual\/organization listed below<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_54_6_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.2' type='checkbox'  value='Yes request'  id='choice_54_6_2' tabindex='27'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_54_6_2' id='label_54_6_2' class='gform-field-label gform-field-label--type-inline'>request information from the individual\/organization listed below<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_54_50\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_50\" ><label class='gfield_label gform-field-label' for='input_54_50'>Name of the Individual\/Organization<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_54_50' type='text' value='' class='medium'   tabindex='28'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_54_25\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_25\" ><label class='gfield_label gform-field-label' for='input_54_25'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_54_25'>Phone number for the Individual\/Organization<\/div><div class='ginput_container ginput_container_phone'><input name='input_25' id='input_54_25' type='tel' value='' class='medium' tabindex='29' placeholder='123-456-7890' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_54_25\"  \/><\/div><\/div><div id=\"field_54_42\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_42\" ><label class='gfield_label gform-field-label' for='input_54_42'>Fax<\/label><div class='gfield_description' id='gfield_description_54_42'>Fax number for the Individual\/Organization<\/div><div class='ginput_container ginput_container_phone'><input name='input_42' id='input_54_42' type='tel' value='' class='medium' tabindex='30'   aria-invalid=\"false\" aria-describedby=\"gfield_description_54_42\"  \/><\/div><\/div><fieldset id=\"field_54_43\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_43\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_54_43'>Address for the Individual\/Organization<\/div>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_54_43' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_54_43_1_container' >\n                                        <input type='text' name='input_43.1' id='input_54_43_1' value='' tabindex='31'   aria-required='true'    \/>\n                                        <label for='input_54_43_1' id='input_54_43_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_54_43_2_container' >\n                                        <input type='text' name='input_43.2' id='input_54_43_2' value='' tabindex='32'    aria-required='false'   \/>\n                                        <label for='input_54_43_2' id='input_54_43_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_54_43_3_container' >\n                                    <input type='text' name='input_43.3' id='input_54_43_3' value='' tabindex='33'   aria-required='true'    \/>\n                                    <label for='input_54_43_3' id='input_54_43_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_54_43_4_container' >\n                                        <input type='text' name='input_43.4' id='input_54_43_4' value='' tabindex='35'     aria-required='true'    \/>\n                                        <label for='input_54_43_4' id='input_54_43_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_54_43_5_container' >\n                                    <input type='text' name='input_43.5' id='input_54_43_5' value='' tabindex='36'   aria-required='true'    \/>\n                                    <label for='input_54_43_5' id='input_54_43_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_43.6' id='input_54_43_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_54_27\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_27\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >For the following purpose, use, or need:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_54_27'><div class='gchoice gchoice_54_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value='Insurance'  id='choice_54_27_1' tabindex='37'  aria-describedby=\"gfield_description_54_27\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_54_27_1' id='label_54_27_1' class='gform-field-label gform-field-label--type-inline'>Insurance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_54_27_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.2' type='checkbox'  value='Coordination of Care'  id='choice_54_27_2' tabindex='38'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_54_27_2' id='label_54_27_2' class='gform-field-label gform-field-label--type-inline'>Coordination of Care<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_54_27_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.3' type='checkbox'  value='Legal'  id='choice_54_27_3' tabindex='39'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_54_27_3' id='label_54_27_3' class='gform-field-label gform-field-label--type-inline'>Legal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_54_27_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.4' type='checkbox'  value='Personal Use'  id='choice_54_27_4' tabindex='40'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_54_27_4' id='label_54_27_4' class='gform-field-label gform-field-label--type-inline'>Personal Use<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_54_27_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.5' type='checkbox'  value='School\/Education'  id='choice_54_27_5' tabindex='41'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_54_27_5' id='label_54_27_5' class='gform-field-label gform-field-label--type-inline'>School\/Education<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_54_27_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.6' type='checkbox'  value='Military'  id='choice_54_27_6' tabindex='42'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_54_27_6' id='label_54_27_6' class='gform-field-label gform-field-label--type-inline'>Military<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_54_27_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.7' type='checkbox'  value='Disability'  id='choice_54_27_7' tabindex='43'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_54_27_7' id='label_54_27_7' class='gform-field-label gform-field-label--type-inline'>Disability<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_54_27_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.8' type='checkbox'  value='Employment'  id='choice_54_27_8' tabindex='44'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_54_27_8' id='label_54_27_8' class='gform-field-label gform-field-label--type-inline'>Employment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_54_27_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.9' type='checkbox'  value='Other'  id='choice_54_27_9' tabindex='45'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_54_27_9' id='label_54_27_9' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_54_27'>Check all that apply<\/div><\/fieldset><div id=\"field_54_10\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_10\" ><label class='gfield_label gform-field-label' for='input_54_10'>Explain:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_10' id='input_54_10' class='textarea medium' tabindex='46'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_54_11\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_11\" ><font size=\"4\">The following information from my psychiatric\/medical records may be disclosed, covering the dates indicated below:<\/font><\/div><div id=\"field_54_45\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_45\" ><label class='gfield_label gform-field-label' for='input_54_45'>Treatment start date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_54_45' type='text' value='' class='medium'  aria-describedby=\"gfield_description_54_45\" tabindex='47'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_54_45'>Can use birth date if exact start date is unknown.<\/div><\/div><div id=\"field_54_41\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_41\" ><label class='gfield_label gform-field-label' for='input_54_41'>Treatment end date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_54_41'>Examples: 12\/31\/2020, case closure, 60 days after case closure, etc.<\/div><div class='ginput_container ginput_container_text'><input name='input_41' id='input_54_41' type='text' value='' class='medium'  aria-describedby=\"gfield_description_54_41\" tabindex='48'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_54_14\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_14\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Information for disclosure:<\/legend><div class='gfield_description' id='gfield_description_54_14'>Check all that apply<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_54_14'><div class='gchoice gchoice_54_14_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.1' type='checkbox'  value='Treatment Summary'  id='choice_54_14_1' tabindex='49'  aria-describedby=\"gfield_description_54_14\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_54_14_1' id='label_54_14_1' class='gform-field-label gform-field-label--type-inline'>Treatment Summary<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_54_14_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.2' type='checkbox'  value='Psychiatric Evaluation'  id='choice_54_14_2' tabindex='50'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_54_14_2' id='label_54_14_2' class='gform-field-label gform-field-label--type-inline'>Psychiatric Evaluation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_54_14_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.3' type='checkbox'  value='Psychological Testing'  id='choice_54_14_3' tabindex='51'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_54_14_3' id='label_54_14_3' class='gform-field-label gform-field-label--type-inline'>Psychological Testing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_54_14_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.4' type='checkbox'  value='Physical Exam'  id='choice_54_14_4' tabindex='52'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_54_14_4' id='label_54_14_4' class='gform-field-label gform-field-label--type-inline'>Physical Exam<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_54_14_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.5' type='checkbox'  value='Laboratory Studies'  id='choice_54_14_5' tabindex='53'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_54_14_5' id='label_54_14_5' class='gform-field-label gform-field-label--type-inline'>Laboratory Studies<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_54_14_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.6' type='checkbox'  value='Initial Assessment'  id='choice_54_14_6' tabindex='54'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_54_14_6' id='label_54_14_6' class='gform-field-label gform-field-label--type-inline'>Initial Assessment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_54_14_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.7' type='checkbox'  value='Exchange of all written and verbal health information pertinent to the coordination of my care and treatment'  id='choice_54_14_7' tabindex='55'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_54_14_7' id='label_54_14_7' class='gform-field-label gform-field-label--type-inline'>Exchange of all written and verbal health information pertinent to the coordination of my care and treatment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_54_14_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.8' type='checkbox'  value='Other'  id='choice_54_14_8' tabindex='56'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_54_14_8' id='label_54_14_8' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_54_14_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.9' type='checkbox'  value='Exclude the following information:'  id='choice_54_14_9' tabindex='57'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_54_14_9' id='label_54_14_9' class='gform-field-label gform-field-label--type-inline'>Exclude the following information:<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_54_35\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_35\" ><label class='gfield_label gform-field-label' for='input_54_35'>Other:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_35' id='input_54_35' class='textarea medium' tabindex='58'    aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_54_36\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_36\" ><label class='gfield_label gform-field-label' for='input_54_36'>Description of information to be excluded:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_36' id='input_54_36' class='textarea medium' tabindex='59'    aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_54_17\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_17\" ><font size=\"3\">I acknowledge such information cannot be disclosed without my written informed consent unless otherwise provided by law. I further understand that such information to be disclosed may include treatment of Psychiatric, Substance Abuse, and HIV\/AIDS related illnesses. I agree that the information may be faxed for expediency. I have the right to revoke this authorization at any time. Any revocation will be done in writing to the attention of the Medical Records Director and any information previously authorized and released will not be subject to revocation. I acknowledge and authorize that the\ninformation indicated on this form will be sent to the individual listed above. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) protects the privacy of health information. Persons or organizations receiving this health information may not be bound by the provisions of this law. However, re-disclosure of this information is prohibited by the Michigan Mental\nHealth Code (sections 748, 749 and 750 of the Public Act 258 of 1974 as amended) and also by Title 42 of the Code of Federal Regulations, Part II, with which this authorization complies. The released information may not be copied, shared or re- released, except as consistent with the authorized purpose stated above. I understand that I am not required to sign this authorization, and that Pine Rest will not refuse me treatment if I refuse to sign. I have the right to inspect and obtain a copy of the information disclosed. A true and exact photocopy\/faxed copy of this authorization shall have the same effect as the\noriginal.<\/font><\/div><fieldset id=\"field_54_51\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_51\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Intent of Release<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_54_51'>Please select one or both, as applicable.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_54_51'><div class='gchoice gchoice_54_51_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.1' type='checkbox'  value='Send 30 days'  id='choice_54_51_1' tabindex='60'  aria-describedby=\"gfield_description_54_51\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_54_51_1' id='label_54_51_1' class='gform-field-label gform-field-label--type-inline'>I am requesting records be sent to the above named person\/organization within the next 30 days<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_54_51_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.2' type='checkbox'  value='For file'  id='choice_54_51_2' tabindex='61'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_54_51_2' id='label_54_51_2' class='gform-field-label gform-field-label--type-inline'>I am to have this form on file and it may be used to communicate with or send records to the above named person\/organization if needed prior to the expiration date<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_54_18\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_18\" ><label class='gfield_label gform-field-label' for='input_54_18'>If no expressed revocation is issued, this authorization will expire one year from the date indicated after my electronic signature or upon the following date, event or condition:<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_54_18' type='text' value='' class='medium'   tabindex='62'   aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_54_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_19\" ><legend class='gfield_label gform-field-label' >I would like someone to explain this form to me.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_54_19'>\n\t\t\t<div class='gchoice gchoice_54_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Yes'  id='choice_54_19_0' onchange='gformToggleRadioOther( this )'  tabindex='63'  \/>\n\t\t\t\t\t<label for='choice_54_19_0' id='label_54_19_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_54_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='No'  id='choice_54_19_1' onchange='gformToggleRadioOther( this )'  tabindex='64'  \/>\n\t\t\t\t\t<label for='choice_54_19_1' id='label_54_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_54_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_20\" ><legend class='gfield_label gform-field-label' >I would like a copy of this release form mailed to me.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_54_20'>\n\t\t\t<div class='gchoice gchoice_54_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Yes'  id='choice_54_20_0' onchange='gformToggleRadioOther( this )'  tabindex='65'  \/>\n\t\t\t\t\t<label for='choice_54_20_0' id='label_54_20_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_54_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='No'  id='choice_54_20_1' onchange='gformToggleRadioOther( this )'  tabindex='66'  \/>\n\t\t\t\t\t<label for='choice_54_20_1' id='label_54_20_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_54_37\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_37\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >This document was completed and submitted by the patient\/parent\/legal guardian and constitutes an electronic signature for this release of information.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_54_37'>Submitting this form for someone other than yourself or legally guarded person is considered fraudulent and will not be accepted.<\/div><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_54_37'>\n                            \n                            <span id='input_54_37_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_37.3' id='input_54_37_3' value='' tabindex='68'  aria-required='true'     \/>\n                                                    <label for='input_54_37_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_54_37_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_37.6' id='input_54_37_6' value='' tabindex='70'  aria-required='true'     \/>\n                                                    <label for='input_54_37_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_54_44\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown col-xs-24 col-sm-8 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_54_44\" ><legend class='gfield_label gform-field-label' >Signature Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_54_44' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_54_44_1_container'><select name='input_44[]' id='input_54_44_1' tabindex='72'  aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_54_44_2_container'><select name='input_44[]' id='input_54_44_2' tabindex='73'  aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_54_44_3_container'><select name='input_44[]' id='input_54_44_3' tabindex='74'  aria-required='true'  ><option value=''>Year<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><div id=\"field_54_31\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" 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type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 54, 'https:\/\/forms.pinerest.org\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', false );jQuery('#gform_ajax_frame_54').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_54');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_54').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 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