Medical Records Release Form

Patient Name *

First Name Last Name

Date of Birth *

Date

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Please enter a valid phone number.

This request is being sent to: *

Address *

Street Address

Street Address Line 2

City State / Province

Fax Number (or phone if fax unknown) *

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 888-9393-4124)

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?: *

Yes No

Information to be released: *

Complete records, including lab and imaging reports, vaccinations, and preventive measures I 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 above Copies 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

Select *

I am the patient I am the legal guardian for the patient (indicate relationship below)*

*Relationship