medical records release

DeLeo Family Medicine, PC
145 Sawkill Road
Kingston, NY 12401
Telephone: (845) 853-7003
Fax: (845) 853-7002

Medical Records Release Form

The protected information that the provider will use or disclose includes my complete medical records or the patient’s complete medical record if minor/guardianship involved, including but not limited to my name or patient’s/minor’s name, telephone number, social security number, insurers, payers, prior medical history, current medical issues, diagnoses, operative procedures, course of treatment, payment information and all documentation and test results created thereby.

Persons Authorized to make the Disclosure: Any employee of the provider is authorized to disclose the protected health information.

Obtain Records From (Name and Address)

Patient's Name

SS#

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

DOB

Release All Records:

Purpose of Release

Release last two (2) years of records and any pertinent past medical history to include

Release Specific Information:

Authorization: I hereby authorize the release of my medical records or medical records (for the patient indicated above if minor or guardianship) involved, covering all medical records regarding treatment, impatient and outpatient care. I release that this may specifically include information about psychological or psychiatric conditions: drug abuse, alcoholism, Acquired Immune Deficiency Syndrome and/or human immunodeficiency virus. (New York State law requires these conditions to be specified, my signature does no imply that any of them apply to me

Patient's Right to Revoke: I understand that I may revoke this authorization at any time by writing a letter to the provide stating my authorization is revoked. The letter must be addressed to the "Privacy Officer" at the providers' current address. However, if the provider has relied on my authorization and has taken action on my protected health information, my revocation shall not be

Redisclosure by Recipient: I understand that once the provider discloses the protected health information to a recipient, the recipient may redisclose the information which may no longer be protected by the federal or state law.

Acknowledgement of Reading and Agreement: By signing below, I agree that I have read and understand this authorization. If a representative of the patients signs this authorization, i.e., guardian/parent, the representative has the authority to act on behalfof the patient.

Signature of Patient

Date

Signature of Parent/Guardian

Print Name of Parent/Guardian