Medical Records Release Form

Medical Records Release Form
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Previous physician/clinic:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number
I hereby authorize the above physician/practice/facility to release my individually identifiable health information as outlined below to:

Direct Family Care of Northern Colorado

(Fort Collins, CO, Ph 970-632-4931, F 888-939-4124)

126 W. Harvard St. Suite 1, Fort Collins, CO, 80525

which may include information concerning such as laboratory and imaging reports, medical history, treatment, and any other such related information. I understand that this authorization is voluntary and I may refuse to sign it. I further understand that my health care and the payment of my health care will not be affected if I do not sign this form, and I will be provided a signed copy of the form if requested. I understand written notification is necessary to cancel this authorization. To obtain information on ot to withdraw my authorization or to recieve a copy of my withdrawal I may contact Direct Family Care at 970-632-4931. I am aware that the revocation will not apply to inforamtion that has already been released in response to this authorization.
Authorized?:*

YesNo
Information to be released:*

Complete records, including lab and imaging reports, vaccinations, and preventive measuresI only need the following records:
In compliance with the Colorado Mental Health Procedures Act:

Copies of medical records pertaining to diagnosis and/or treatment of psychiatric, psychological conditions and/or drug or alcohol abused may be released to the recipient as noted aboveCopies of medical records, including information of the diagnosis and/or treatment for AIDS/HIV (including testing) may be released ot the recipient as noted above.
Include dates of service: Date to Date
Purpose of releasing records
Signature

Clear
Date

MonthDayYear
Date
Select*

I am the patientI am the legal guardian for the patient (indicate relationship below)*
*Relationship
Should be Empty: