RECORDS RELEASE

MEDICAL RECORDS FROM: Family Medicine Associates, INC 8853 Fox Dr Suite 200 Thornton, CO 80260 Phone: 303-487-8817 Fax: 303-487-0429
SEND MEDICAL RECORDS TO: Doctor/Practice Name*
Phone*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax ( FAX # MUST BE PROVIDED , RECORDS WILL NOT BE SENT WITHOUT IT) *
Patient Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Phone*
DO YOU authorize the release of information related to HIV/AIDS, psychological or psychiatric conditions, and treatment for alcohol and/or drug abuse.
DO YOU authorize the release of information related to HIV/AIDS, psychological or psychiatric conditions, and treatment for alcohol and/or drug abuse. ANSWER I DO OR I DO NOT*
Release the following records:*

2 years. Medical records generated by Family Medicine Associates, PC, including progress notes and diagnostic results.Only a portion of Family Medicine Associates records, please explain belowOther please explain below
Explain your choice, for example.. only Labs, xrays or All
*There is a charge for a personal copy of your records.
Purpose of Disclosure:

PERMANENT TRANSFERReferral to SpecialistsPersonal (there is a fee)InsuranceWorkers CompLegal InvestigationDisability DeterminationOtrher
This Authorization is valid for 1 year from the date of signature unless otherwise indicated

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Patient Rights: I understand I do not have to sign this authorization in order to get health care benefits (treatment, payment, or enrollment However, I do have to sign and authorization form: *To take part in a research study. * To receive health care when the purpose is to create health information for a third party. I may revoke this authorization in writing. If | do, It will not affect any actions already taken by the above named practices based upon this authorization. I may not be able to revoke this authorization if its purpose was to obtain insurance. Two ways to revoke this authorization are: *Fill out a revocation form (available from our office) or written communication to the office. Once the office discloses health information, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it.
Signature*

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Date*

MonthDayYear
Date
Printed Name*
Relationship*
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