Medical Records Release Form

Medical Records Release Form

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION
PATIENT INFORMATION
Patient's Name:*

First NameLast Name
Patient's Date of Birth:*

MonthDayYear
Date
Patient's Social Security:
Patient's Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Patient's Phone:*
Format: (000) 000-0000.
Email:
example@example.com
MY AUTHORIZATION
I voluntarily consent to and authorize Hope Health to:
Select one:*
Note: if the patient is requesting a copy of their own medical records, select "Release My Health Care Information To" and write in patient's personal information below)
Name of Organization or Individual to Receive Medical Records:*
Name of Organization or Individual to Obtain Medical Records From:*
Phone Number of Organization or Individual*
Format: (000) 000-0000.
Address of Organization or Individual*

Street Address

Street Address Line 2

CityState

Zip Code
PURPOSE
I authorize the release of my health care information for the following purpose*
Note: "at the request of the patient" is sufficient if the patient is initiating this authorization
INFORMATION TO BE DISCLOSED
All of my health information that the provider has in his/her possession, including information relating to any medical history, mental or physical condition, and any treatment received by me.Dental RecordsOnly the following records or types of health information (please list in the white space provided below)
specific records or types of health information:
TERM
I understand that this authorization will remain in effect based on the selection below:
Until the Provider fulfills this requestUntil the following event occurs (please describe in the white space provided below)From the date of this Authorization until:
please describe "event"
MonthDayYear
date the authorization expires

REDISCLOSURE
I understand that Hope Health cannot guarantee that the recipient will not redisclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information.
REFUSAL TO SIGN/RIGHT TO REVOKE
I understand that signing this form is voluntary and that if I don’t sign, it will not affect the commencement, continuation or quality of my treatment at Hope Health. If I change my mind, I understand that I can revoke this authorization by providing a written notice of revocation to Hope Health. The revocation will be effective immediately upon Hope Health’s receipt of my written notice, except that the revocation will not have any effect on any action taken by Hope Health in reliance on this Authorization before it received my written notice of revocation.
QUESTIONS
I may contact Hope Health for answers to my questions about the privacy of my health information by telephone at (972) 923-2440, email at info@hopehealthtx.org or in person at the Waxahachie or Ennis location.
SPECIFIC AUTHORIZATIONS
Sexually Transmitted Disease (STD) as defined by law, includes Herpes, Herpes Simplex Virus, Human Papilloma Virus, Condyloma (genital warts), Chlamydia, Non-specific Urethritis, Syphilis, VDRL, Chancroid, Lymphogranuloma Venereum,
HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and Gonorrhea.
I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.
YesNo
I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above.
YesNo
FEES
Hope Health strongly encourages the receipt of medical records through fax/email to prevent fees associated with printing. If medical records are released directly to the patient in the form of a paper copy, a fee of $10.00 for the first 20 pages and $0.20 for each additional page will be charged.
REQUIRED SIGNATURES
YesNo
Date*

MonthDayYear
Date
Patient's Signature*

Clear
Name of Guardian/Representative*

First NameLast Name
Date*

MonthDayYear
Date
Guardian or Representative Signature*

Clear
Should be Empty:

Medical Records Release Form

PATIENT INFORMATION

MY AUTHORIZATION

PURPOSE

INFORMATION TO BE DISCLOSED

TERM

REDISCLOSURE

REFUSAL TO SIGN/RIGHT TO REVOKE

QUESTIONS

SPECIFIC AUTHORIZATIONS

FEES

REQUIRED SIGNATURES