breakthroughchiro.com - Patient Request for Medical Records

PATIENT REQUEST FOR MEDICAL RECORDS
Patient Name: *
Date:*

MonthDayYear
Date
Date of Birth:*

MonthDayYear
Date
Last 4-digits of SS:*
I hereby request and authorize:
To request information my health information from:

Provider’s OfficeHospitalOther
Information to be disclosed includes copies of:

Copy of Patient RecordsCopy of X-ray, CT, MRI Report(s)Copy of Medication ListCPAP Compliance (last 30 days)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:

Clear
Date:*

MonthDayYear
Date
Signature of Legal Representative/Relationship:

Clear
Date:

MonthDayYear
Date
If signing for a minor patient, I hereby state that my parental rights have not been revoked by a court of law.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