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*

MonthDayYear
Date
Entity Requested to Release Information*

Capital Orthopaedics & Sports Medicine, P.C.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?*

Please FAX* this information to the entity above.Please MAIL* this information to the entity abovePlease EMAIL* this information to the entity aboveThe entity above will PICK UP this information in-person. (if you are picking up, you must be listed as the individual authorized to receive 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.
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:*

Entire patient recordor check only those record items to be disclosed
Check Items to be disclosed.

office noteslab results; pathologyimaging reportsfinancial history reportnursing home, home health, hospice notesmental health/substance abuse treatmentHIV/communicable disease testing recordONLY disclose the following:
Purpose of Disclosure*

Patient RequestFMLA/Disability *$25 processing fee applies per set of forms*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:

MonthDayYear
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*

MonthDayYear
Date
Relationship
Should be Empty: