breakthroughchiro.com - Patient Request for Medical Records

PATIENT REQUEST FOR MEDICAL RECORDS
Patient Name:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Last 4-digits of SS:
I hereby request and authorize:
To request information my health information from:

Other
Information to be disclosed includes copies of:

Other:
This authorization will be effective for six months after the date signed, unless cancelled in writing. I understand that the cancellation will have no effect on information released prior to receiving the cancellation. A copy of this authorization is as valid as the original.
Signature of Patient:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature of Legal Representative/Relationship:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If signing for a minor patient, I hereby state that my parental rights have not been revoked by a court of law.

Notice to recipient of information: This information has been disclosed to you from confidential records, which are protected by law. Unless you have further authorization, laws may prohibit you from making any further disclosures of this information without the specific written consent of the patient or legal representative.
Should be Empty:

PATIENT REQUEST FOR MEDICAL RECORDS