Medical Records Release Form (Leaving Circle Care Center- Norwalk)

618 West Avenue. Norwalk, CT 06850
HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT INFORMATION PURSUANT TO 45 CFR 164.508
From:

Circle Care Center

618 West Avenue

Norwalk, CT 06850-4008

Phone: 203-852-9525

Fax: 203-854-0371
RE: Patient Name
Date of Birth

MonthDayYear
Date
Social Security Number

I authorize and request the disclosure of all protected information for the purpose of review and evaluation by the Recipient. I expressly request that the designated record custodian of all covered entities under HIPAA identified above disclose full and complete protected medical information including the following:

All medical records, meaning every page in my record, including but not limited to: office notes, face sheets, history and physical, consultation notes, inpatient, outpatient and emergency room treatment, all clinical charts, reports, order sheets, progress notes, nurse's notes, social worker records, clinic records, treatment plans, admission records, discharge summaries, requests for and reports of consultations, documents, correspondence, test results, statements, questionnaires/histories, correspondence, photographs, videotapes, telephone messages, and records received by other medical providers.All physical, occupational and rehab requests, consultations and progress notes.All disability, Medicaid or Medicare records including claim forms and record of denial of benefits.All employment, personnel or wage records.All autopsy, laboratory, histology, cytology, pathology, immunohistochemistry records and specimens; radiology records and films including CT scan, MRI, MRA, EMG, bone scan, myelogram; nerve conduction study, echocardiogram and cardiac catheterization results, videos/CDs/films/reels and reports.All pharmacy/prescription records including NDC numbers and drug information handouts/monographs.All medical information pertaining to the above-mentioned individual to be disseminated via telephone and verbal conversations only.
All billing records including all statements, insurance claim forms, itemized bills, and records of billing to third party payers and payment or denial of benefits for the period Date* to Date* .
I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), and alcohol and drug abuse. I authorize the release or disclosure of this type of information.
This protected health information is disclosed for the following purposes:

FOR CONTINUITY OF HEALTHCARE
This authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records of 42 CFR 2.31, the restrictions of which have been specifically considered and expressly waived.
You are authorized to release the above records to the following medical personnel/facility and/or representatives of defendants in the above-entitled matter who have agreed to pay reasonable charges made by you to supply copies of such records:
Name of Representative

First NameLast Name
Representative Capacity (e.g. attorney, records requestor, agent, etc.)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid fax number.
I understand the following: See CFR §164.508(c)(2)(i-iii)

a. I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization.

b. The information released in response to this authorization may be re-disclosed to other parties.

c. My treatment or payment for my treatment cannot be conditioned on the signing of this authorization.

Any facsimile, copy or photocopy of the authorization shall authorize you to release the records requested herein. This authorization shall be in force and effect until one year from date of execution at which time this authorization expires.
Signature of Patient or legally Authorized Representative ((See 45CFR § 164.508(c)(1)(vi)) *

Clear
Today's date*

MonthDayYear
Date
Name and Relationship of Legally Authorized Representative to Patient (See 45CFR §164.508(c)(1)(iv))

First NameMiddle NameLast NameRelationship
Witness Signature*

Clear
Today's date

MonthDayYear
Date
THIS MEDICAL RELEASE EXPIRES ONE YEAR FROM DATE OF SIGNATURE
Should be Empty:

618 West Avenue. Norwalk, CT 06850

HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT INFORMATION PURSUANT TO 45 CFR 164.508

This protected health information is disclosed for the following purposes:

This authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records of 42 CFR 2.31, the restrictions of which have been specifically considered and expressly waived.

You are authorized to release the above records to the following medical personnel/facility and/or representatives of defendants in the above-entitled matter who have agreed to pay reasonable charges made by you to supply copies of such records:

THIS MEDICAL RELEASE EXPIRES ONE YEAR FROM DATE OF SIGNATURE