bamapeds.com - Medical Record Release Form

Medical Record Release Form
Bama Pediatrics and Allergy 2701 20th Ave, Northport, AL 35476 | Phone: (205) 333-5900
Patient’s Name
Date of Birth:

MonthDayYear
Date
I authorize Enter Name to use or release/disclose my health information as described below. Please identify the information to be released:
OR
Please release only the following information
The identified information will be used for the following purposed:

Other
Please initial each item below to indicate your understanding:
I understand the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.
I understand once the information below is release, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations.
I understand I have a right to revoke this authorization at any time. I understand if I revoke this authorization, I must do so in writing and present my written revocation to the practice. I understand the revocation will not apply to information that has already been released in response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy
I understand authorizing the use or release of this information is voluntary. I need not sign this form to ensure heath care treatment
Reason for leaving the practice:
The identified information may be used by or released to the following individual(s) or organization(s):
Name:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Address:
Fax:
This authorization will expire on

MonthDayYear
Date
If I fail to specify an expiration date or event, this authorization will expire in twelve (12) months from the date on which it was signed.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Patient Signature:
Date:

MonthDayYear
Date
If not Self, Relationship to Patient
Should be Empty:

Medical Record Release Form

Please initial each item below to indicate your understanding: