Request for Medical Records

Request for Release of Protected Health Information

Please fill in all information. Form must be signed and dated with all blanks filled in. Failure to do so may delay or prevent release of info.

Patient Name

First NameLast Name

Date of Birth

Date

Entity Requested to Release Information

Other

Who will be authorized to receive information

I authorize the entity identified above to disclose or provide protected health information (PHI) to the individual/entity listed below:

Individual/Identity Name:

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How would you like the above entity to receive this information?

*Secure communication: Note that some fax and email methods are not secure, and it is possible for your PHI to be compromised during transmission. If this is of concern to you, we recommend either choosing to have your information mailed or picking up your information in-person from our Clive office when it is ready.

Please FAX* this information to the entity above at the following fax number:

Please enter a valid phone number.Format: (000) 000-0000.

Please MAIL* this information to the entity above at the following address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please EMAIL* this information to the entity above at the following address:

example@example.com

Description of Information to be Disclosed

I authorize the entity identified above to disclose the following PHI to the individual/entity identified above:

Check Items to be disclosed.

Office Notes able to be disclosed?

Imaging Reports able to be disclosed?

Nursing home, home health, hospice notes able to be disclosed?

HIV/communicable disease testing record able to be disclosed?

Lab results; pathology able to be disclosed?

Financial history report able to be disclosed?

Mental health/substance abuse treatment able to be disclosed?

Office notes able to be disclosed?

Imaging reports able to be disclosed?

Nursing home, home health, hospice notes able to be disclosed?

HIV/communicable disease testing record able to be disclosed?

Lab results; pathology able to be disclosed?

Financial history report able to be disclosed?

Mental health/substance abuse treatment able to be disclosed?

Only disclose the following:

Purpose of Disclosure

Other

This authorization will expire 1 year after the date of signature, unless an earlier termination date is specified. Please stipulate the termination date if you do not wish this authorization to remain valid for 1 full year:

Date

You have the right to terminate this authorization at any time by submitting a written request. Termination of this authorization will be effective upon written notice, except where a disclosure has already been made based on prior authorization.
The practice places no condition to sign this authorization on the delivery of healthcare or treatment.
We have no control over the person(s) you have listed to receive your PHI. Therefore, the PHI disclosed under this authorization may no longer be protected by the requirements of the Privacy Rule and will no longer be the responsibility of the practice.

Signature of Patient or Patient Representative

If signed by representative Type Name:

Name

Date

Relationship