Medical Records Release Authorization

Medical Records Release Authorization
Patient Name

First NameLast Name
Maiden/Previous Name
Date of Birth

MonthDayYear
Date
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email (note-you must provide an email address if you wish the requested records to be delivered by email).
example@example.com
Please choose the Amberwell location(s) from which you would like your records released from the list below.
Please indicate the method by which you would like the requested records delivered. Please note that if you choose to have delivery by mail or email, the address you provided above will be used for delivery. Please ensure the information you entered is correct before submitting this form.
I am authorizing release of:
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?
Please indicate which specific type of record you would like released:
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
This authorization will expire one year from the above date unless I specify an expiration date: Date
Please provide the final four digits of your social security number.
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
Signature Date

MonthDayYear
Date
For employee use-What is the disposition of this request?
Released by:
Date of records release

MonthDayYear
Date
Signature of employee granting access
Denial of Access with no Right of Review reason?
Denial of Access with Right of Review Reason
Should be Empty: