www.avantemedicalcenter.com - Authorization to Use and Disclose Health Information

Medical Records Release Form
Authorization to Use and Disclose Health Information
Authorization Requesting Health Information FROM Following Entity or Provider
Provider / Entity
Phone*
Please enter a valid phone number.
Fax Number
Authorization to Disclose Health Information FOR the Following Patient
Name*

First NameLast Name
Birth Date*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Current Address*
City,State, Zip
Authorization to Disclose Health Information TO the Following Recipient
Provider / Entity
Phone*
Please enter a valid phone number.
Current Address*
City,State, Zip
Receive by*

MailPick upVerbal ExchangeFax Number
Fax Number*
The Purpose of the Disclosure is

My Personal UseProvider Requested
I Hereby Request

To ReviewTo Copy
For the date range of to Or pertaining to
Health Information needed by*

ASAP / EmergentDate Needed
Date

MonthDayYear
Date
Please send the information as indicated

Discharge SummaryProgress NotesEmergency Dept VisitPsychiatric ReportsX ray Films/ImagesLab ResultsX Ray ReportsMost Recent VisitOther
If "Other" Explain
TERM: I understand this authorization is specifically for information created from services provided before my date of signature. Information
related to services provided after my date of signature will require an updated authorization. This authorization will expire (insert date or event): If I fail to specify an expiration date or event, this authorization will expire six months from the date on which it was signed.
- I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to Avante Medical Center. I understand that the revocation will not apply to information that had already been released in response to this authorization.
- I understand that once the above information is disclosed, it may be redisclosed by the recipient, and the information may not be protected by federal privacy laws or regulations.
- I understand authorizing the use or disclosure of the information identified above is voluntary. I need to sign this form to ensure healthcare treatment.
- I understand that the information in my health record may include information relating to sexually transmitted diseases, AIDS, or HIV. It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.
Name*

First NameLast Name
Signature of Patient or Legal Representative*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Medical Records Release Form

Authorization to Use and Disclose Health Information