08. Medical Records Request Form

Medical Records Request Form
Date Today *

Month Day Year
Date
By completing this form, I hereby authorize Richmond Spine Interventions & Pain
Center to release/obtain the health information indicated below contained in my
patient records to/from the recipient named below.
Information Requested For:
Patient Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Date
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Information/Medical Records Needed: *

Radiology Images Radiology Reports Laboratory Reports Pathology Reports Office/Procedure Notes Other
For other, type here: *
Information/Medical Records stated above are to be: *

Released to Obtaned from
Name *
Person/Provider/Facility/School/Attorney etc.
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Fax Number

Area Code Phone Number
Delivery options: *

Mail copies to address above Fax To be picked up by
Please indicate the recipient's full name
By signing this document, I understand that I have the right to revoke this authorization. My revocation will not be effective until delivered in writing to the person in possession of my records. I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. A copy of my revocation shall be maintained. Information disclosed by this authorization may be re-disclosed by the recipient and would no longer be protected by federal privacy regulations. The provider/facility will not condition treatment on whether I sign the authorization. If the patient is 17 years of age or younger, the patient's parent or legal guardian must sign and date the form, unless an exception* exists under State or Federal law.
Signature

Clear
Name of person signing: *
Date *

Month Day Year
Date
Relationship to patient *

myself parent legal guardian
This form may be used to obtain or request information from another facility for
continuity of care and does not require patient authorization.

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