Medical Records Release Authorization

Medical Records Release Authorization
Patient Name*

First NameLast Name
Maiden/Previous Name
Date of Birth*

MonthDayYear
Date
Home Phone
Please enter a valid phone number.
Cell Phone/Work Phone
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Please choose the Amberwell location(s) from which you would like your records released from the list below.

Amberwell Hiawatha, 300 Utah Street, Hiawatha, KS 66434Amberwell Atchison, 800 Raven Hill Drive, Atchison, KS 66002Amberwell Eighth Street Clinic, 801 Atchison Street, Atchison, KS 66002Amberwell Highland Clinic, 415 West Main Street, Highland, KS 66035Amberwell Lansing Clinic, 1004 Progress Drive, Suite 180, Lansing, KS 66043Amberwell Horton Clinic, 1903 Euclid Avenue, Horton, KS 66439Amberwell Troy Clinic, 311 W. Locust Street, Troy, KS 66087
I am authorizing release of:*

A copy of my recordsAccess to (view) records
Please specify the date range you would like the records you are requesting to cover:
From

MonthDayYear
Date
To

MonthDayYear
Date
What types of records are you authorizing release of?*

all available recordsspecific types of records
Please indicate which specific type of record you would like released:

Lab/Path ReportsOperative/Procedure ReportsER ReportsRadiology/CT/MRI ReportsOther Hospital Reports
Please send/give the requested information to:
Person's name:
First Name*   Last Name*

Relationship (if other than patient)
Relationship*

Address:
Street Address*      City*   State*   Zip*

Phone Number
   Phone Number

Fax Number
   Fax Number
I am releasing my records for the purpose of*

ongoing careother
This authorization will expire one year from the above date unless I specify an expiration date: Date
Please provide your driver's license or government issued ID#.
Please upload a photo of your drivers license or government issued ID.

Cancelof
Please provide the expiration date of your driver's license or government issued ID.

MonthDayYear
Date
All the information you have entered into this form so far will be included in your medical records request.

Please view the informationand ensure it is correct.

If you find anything to be incorrect, please go back to the form, and re-enter the information correctly, and then return to this page, and ensure correctness.

If all is correct, please submit your request.
Signature

Clear
Signature Date

MonthDayYear
Date
For employee use-What is the disposition of this request?

Access GrantedDenial of Access with no Right of ReviewDenial of Access With Right of Review
Released by:

Direct to patientFaxMailedRequest given to copy service
Date of records release

MonthDayYear
Date
Signature of employee granting access

Clear
Denial of Access with no Right of Review reason?
Denial of Access with Right of Review Reason
Should be Empty: