NBH Record Release

Record Release Request Form

Date of Request: *

Patient's Name: *

First Name Last Name

Date of Birth: *

Best Number: *

Area Code Phone Number

Purpose of Release *

Medical Care School or Camp Insurance Personal Legal Matter

Format of Release *

I would like my records emailed to me (enter email below). I would like my records mailed to me (enter address below). I would like my records faxed (enter fax below). I would like to pick up my records in the Norwood Office. I would like to pick up my records in the Franklin Office.

Mail/Fax to:

Name/Doctor's Office

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Fax Number:

Area Code Phone Number

Email

example@example.com

Please note: This email is not encrypted. Records are sent in a pdf format to the email address entered.

Request Type *

Full medical record Other- specify information to be released below:

I hereby authorize Norwood Behavioral Health to release any medical information as requested above. This may include information about drug or alcohol use, psychiatric, social work, or other protected information unless otherwise excluded, such as psychotherapy notes. I am aware that Norwood Behavioral Health cannot control how the recipient uses or shares the information, and that laws protecting its confidentiality at Norwood Behavioral Health may or may not protect this information once it has been disclosed to the recipient.

Signature *

Clear

Name *

First Name Last Name

Relationship to patient *