Records Release Form-Page 4

Release of Medical Records

Complete this form to allow Carlden Health Family Clinic to either release or receive your medical records. Please type your name, select your date of birth, enter the details of your release, sign your name, and hit Submit. For the "Other Facility" details, please provide the information for the person / facility involved in the transfer that is not Carlden Health. Fees may apply for paper copies of records, but electronic copies can be sent for free. Once you successfully complete the form, you will receive an email receipt and be transferred to a confirmation screen. Please call our office if you do not receive this confirmation, or if you have any questions. Thank you!
Patient's Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Who do you want to SEND these records?*

Carlden Health Family ClinicClick to type the name of the person / facility that will SEND these records.
Who do you want to RECEIVE these records?*

Carlden Health Family ClinicMyselfClick to type the name of the person / facility that will RECEIVE these records.
What is the REASON for your request to release medical records?
Which records would you like to be released? You may select more than one.

Most Recent Office Visit & Labs (Default)Most Recent Annual Wellness ExamMost Recent LabsMost Recent Hospital NotesAll Records (Last 3 Years)All Records (Last 3 Months)All Records for a Specific Diagnosis (Please Specify Below)All Office Visit NotesOther
Which records would you like to restrict from being released? (Do Not Send)*

No Restrictions (Default)Alcohol / Drug Abuse NotesSTD / HIV ResultsMental Health RecordsAll Lab ResultsAll ProceduresAll Phone / Email / Portal MessagesOther
HOW do you want these records to be sent?*

Fax (Default)In-Person Pick-UpPatient PortalEmail (Some Restrictions Apply)USPS MailOther
The "Other Person / Facility" is the sender / recipient involved in this transfer that is not Carlden Health. What is the Other Person / Facility's PHONE NUMBER?
N/A for all incoming requests to Carlden Health.
What is the Other Person / Facility's FAX NUMBER?
Carlden Health's fax number is 301-447-0771.
What is the Other Person / Facility's MAILING ADDRESS?
Carlden Health's mailing address is 198 Thomas Johnson Dr, Frederick, MD 21702.
Standard processing time is generally 2 weeks for normal requests, 2 days for urgent requests, and 2 hours for desperate requests. If you require an alternate time frame for any reason, please call our office. How would you like to be notified when your request has been completed and your records have been sent?*

Patient Portal Message (Default)EmailPhone Call
Do you have any notes for our staff that you'd like to add to this request?
I request that information about my healthcare and treatment be released as set forth on this form. This authorization covers all records that I have indicated above for release. This authorization covers information related to alcohol and drug abuse, mental health treatment, and sexually transmitted diseases, unless otherwise indicated. I have the right to revoke this authorization at any time by signing a written statement. This authorization will expire 365 days after the date I have signed below, unless otherwise indicated. I understand that this authorization is voluntary. I understand that a charge may apply for these medical records and may be payable to the facility that is releasing the information under Maryland law (Health General Sec. 4-304).

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Please verify that you are human*
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Release of Medical Records