Phoenician Cardiology - Medical Release Form

AUTHORIZATION FOR RELEASE OF RECORDS

IN ORDER TO RELEASE OR OBTAIN YOUR RECORDS, ALL OF THE FOLLOWING INFORMATION MUST BE OBTAINED. IF ANY INFORMATION IS LEFT BLANK, YOUR REQUEST WILL NOT BE PROCESSED.

Date

Patient's Name

DOB

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Daytime Phone #

Are you transferring out of our facility?

YesNo

If yes, reason for leaving practice?

I authorize Phoenician Cardiology to:

OBTAIN my records fromRELEASE my records to

*If releasing records to self, charges will apply*

Facility Name:

Doctor's Name:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone #

Fax #

I HEARBY CONCENT TO THE RELEASE OF ALL MEDICAL RECORDS AND OTHER DOCUMENTATION PERTAININGTO THE MEDICAL CARE RECEIVED IN THIS FACILITY, INCLUDING THE FOLLOWING:

ALL TREATMENT**LAB REPORTS/X-RAY REPORTSTREATMENT RELATED TO SPECIFIC INJURY OR ILLNESSBEGINNING AND ENDING DATES OF TREATMENT

Please specify Treatment Related to Specific Injury or Illness

Please specify Beginning and Ending Dates of Treatment

**I UNDERSTAND THAT I AM ONLY OBTAINING THE RECORDS PRODUCED BY THIS FACILITY AND NOT THE RECORDS THAT WERE FORWARDED FROM ANY PREVIOUS PRIMARY CARE PHYSICIANS, I SPECIFICALLY CONSENT TO THE RELEASE OF ANY INFO CONTAINED IN THE MEDICAL RECORDS, WHICH MAY RELATE TO THE INFECTION WITH HUMAN IMMUNODEFICIENCY VIRUS (HIV), AIDS OR RELATED CONDITIONS, AS WELL AS INFORMATION REGARDED AS CONFIDENTIAL.

** I UNDERSTAND THAT PHOENICIAN CARDIOLOGY HAS NO RESPONSIBILITY FOR THE USE OR DISTRIBUTION OF THIS INFORMATION BY THE PARTY TO WHOM IT IS RELEASED. I RELEASE PHOENICIAN CARDIOLOGY FROM ALL LIABILITY WHICH COULD ARISE FROM THE COMPLIANCE WITH THIS REQUEST TO RELEASE RECORDS. I AUTHORIZE PHOENICIAN CARDIOLOGY TO TRANSMIT THIS INFORMATION BY FACSIMILE TRANSMISSION (FAX) AND/OR MAIL AND RELEASE PHOENICIAN CARDIOLOGY FROM ANY LIABILITY FOR POTENTIAL BREACH OF CONFIDENTIALITY DUE TO MISDIRECTION OF TRANSMISSION OR FAILURE TO RECEIVE TRANSMISSION OF MY RECORDS.

Patient Signature*

Date*

Date