Release of Medical Records (from another facility to HFFM)

Release of Medical Records

This form grants permission to release medical records to Healing Family Functional Medicine from another healthcare facility. Failure to provide additional identifying information in Section I may result in the inability to respond to this request. This form is not a patient access request under 45 CFR 164.524. Records released pursuant to this authorization may include information concerning testing, diagnosis or treatment of HIV/AIDS, psychiatric and/or drug/alcohol treatment, and/or sexual assault.
Please send medical records to Healing Family Functional Medicine (The office of Seema Patel, MD, MPH, IFMCP):

Phone: 216-440-5559

Fax: 216-502-4141

E-mail: Colleen@HealingFamilyFunctionalMedicine.com.
Patient Name:*

First NameLast Name
Patient Birth Date:*

MonthDayYear
Patient Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Patient E-Mail*
example@example.com
I hereby authorize the disclosure of health information about the above individual as follows:

Please provide the contact information for the Physician/Practitioner/Healthcare system FROM which you are requesting records.
Physician/Practitioner from which you are requesting records:*

First NameLast Name
Hospital/Facility from which you are requesting records: *
Office Phone Number*
Phone number for Physician/Practitioner from which you are requesting recordsFormat: (000) 000-0000.
Office Fax Number*
Fax number for Physician/Practitioner from which you are requesting recordsFormat: (000) 000-0000.
Health Information to be disclosed (Blood tests, x-rays, office visit notes, etc.). Please be as specific as possible: *
Reason for Disclosure
This authorization will remain in effect until revoked or shall expire on date or event specified below. I understand that I may revoke or cancel this authorization at any time by submitting written revocation in the manner specified by the disclosing entity, except to the extent that action has been taken in reliance on this authorization. If this authorization has not been revoked, it will expire on the date or completion of the event stated below. If no date or event is specified below, this authorization will expire in one year.

MonthDayYear
Expiration Date
I understand that I may not be denied treatment, payment, and enrollment in the health plan, or eligibility for benefits for refusing to authorize disclosure unless such denial is permitted under state and federal law. • I understand that information disclosed by this authorization, except as prohibited by 42 CFR Part 2 or other applicable law, may be subject to re-disclosure by the recipient and may no longer be protected by the Health Insurance Portability and Accountability Act Privacy Rule [45 CFR Part 164]. Signature of patient or representative:*
Relationship to Patient
Today's Date:

MonthDayYear
Date
Should be Empty:

Release of Medical Records

I hereby authorize the disclosure of health information about the above individual as follows: