Patient Request for IHCWV Medical Records

Patient Request to Release Medical Records
Patient Name*
Date of Birth*

MonthDayYear
Date
Social Security Number
I authorize Integrated Health Centers of WV (304-643-4005) to release the following medical information by mail or fax to Medical Office: *
Name of Health Care Professional or Facility
Health Care Professional or Facility Address:
Health Care Professional or Facility Phone:
Health Care Professional or Facility Fax:
Please enter a valid fax number
Description of Information to be released:*

All healthcare information on fileHealthcare information relating to a specific treatment/conditionsHealthcare information for specific dates (including health history & physical exam information)Other
Please list treatment/conditions
Healthcare information for specific dates; from

MonthDayYear
Date
Healthcare information for specific dates; to

MonthDayYear
Date
Purpose for this Request:*

Transfer of CareContinuation of CareInsurance CoveragePersonal
Release Format:

Paper CopyCD-Password protected with encryption technology
I acknowledge and consent that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results, or AIDs information:*

YesNot applicable
Please type your initials
Please type your initials
Authorization valid for:*

This Request onlyOne year from the date of this authorizationSelect this option to choose a date
Date authorization is valid until

MonthDayYear
Date
I understand that I may cancel this authorization at any time but submitting a written request, except where a disclosure has already been made in reliance on my prior authorization.
Is the patient under 18?*

YesNo
Relationship to patient
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Patient Request to Release Medical Records