Patient Medical Record Release Form

Patient Medical Record Release Form

Authorization/Disclosure of Health Information

Patient Information
Are you the patient?*

YesNo, I am the patient's personal representative
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Cell Number*
Please enter a valid phone number.
Home Number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

WHERE DO YOU WANT YOUR RECORDS SENT TO?
Check this box if records are being sent to the patient only. If so, you do not need to fill out the rest of this section.
Recipient Name*

First NameLast Name
Organization
Recipient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Recipient Phone*
Recipient Fax or Email*

WHAT IS THE REASON/PURPOSE FOR REQUESTING RECORDS?
*

Permanent TransferReferralOther (Please explain why you are requesting your medical record)

WHAT TREATMENT DATES OF SERVICE ARE YOU LOOKING FOR?
*Date range does not have to be exact. Enter dates to the best of your ability.
*

MonthDayYear
Start Date
*

MonthDayYear
End Date

IS THERE A DEADLINE FOR THIS REQUEST?
We will fulfill your request within 7-10 business days. If you have an urgent need for an upcoming appointment, please let us know and we will do our best to honor your deadline.*

No, just as soon as possibleYes, I have a deadline (please enter the date that you need your record by)
Date

MonthDayYear
Date Needed

EXPIRATION DATE
This authorization shall become effective immediately and remain in effect for 1 year from the date signed below unless specified here*:

MonthDayYear
*Optional Expiration Date (must be 15 days in the future from today's date to be valid)
YOUR RIGHTS UNDER THE LAW
- I may refuse to sign this authorization and my refusal will not affect my ability to obtain treatment or payment.
- I have the right to receive a copy of this authorization.
- I may inspect and obtain copy of my health information for which I am authorizing the use or disclosure for as long as the information is maintained by the affiliate(s) listed above.
- The location(s) listed above will not receive compensation for the use or disclosure of my health information.
- I understand that California law prohibits the recipients of my health information from making further disclosure of my health information unless the recipient obtains another authorization from me or unless the disclosure is required or permitted by law. This protection does not extend to recipients outside the state of California.
*

By Checking this box, I authorize that I have read and I understand my rights under the law.
REVOCATION

I understand that I have a right to revoke this authorization at any time unless action has been taken in response to or in reliance on this authorization. I understand that my revocation must be in writing and presented to a Pathways to Wellness Health Information representative in order to revoke the authorization granted to Pathways to Wellness.

I further understand that I must present a separate written revocation to any other person or entity that I have authorized to receive or use my psychotherapy notes above in order to revoke the authorization granted to that person or entity.
WARNING

PROHIBITIONS ON USAGE, TRANSFER OR REDISCLOSUREOF INFORMATION, except as required by State or Federal laws, use of information released for other than the stated purpose, or redisclosure or transfer of this information to any person or entity not named herein is PROHIBITED. An additional written authorization must be obtained for any proposed new use of the information or for its redisclosure or transfer of such information. The information disclosed may be subject to redisclosure and would no longer be protected by federal privacy regulations. MEDICAL RECORDS WILL BE RETAINED FOR TEN (10) YEARS FOLLOWING A PATIENT’S DISCHARGE FROM OUR AGENCY, WHEREUPON THEY WILL EITHER BE DESTROYEDOR, IF REQUESTED, RETURNED.

SIGNATURE AND DATE
Signature

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Date

MonthDayYear
Date
*If signed by someone other than the patient, print name and specify relationship to the patient.
Name (First and Last)Relationship
Should be Empty:

Patient Medical Record Release Form

YOUR RIGHTS UNDER THE LAW

REVOCATION

WARNING