gsoobgyn.com - Records Release

Authorization for RELEASE of Medical Records
Patient's Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
To Release (check all that apply):

Pap SmearLab Reports (specify, if needed)MammogramPathologyBone DensityBone DensityOffice NotesHospital RecordsOther
Specific Date(s):
Authorize release of information related to AIDS (acquired immunodeficiency syndrome) or HIV (human immunodeficiency virus) infection, sexually transmitted disease(s), psychiatric care and/or psychological assessment and/or treatment for alcohol and/or drug abuse.

I doI do NOT
Send Records To:
Name of Facility
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Purpose of Disclosure:

Referral to SpecialistInsuranceLegal IssueDisabilityPersonalChange of ProviderPCP/InternistWorker's Compensation
I do hereby authorize disclosure of the health information for the above named patient. The authorization is valid for 12 months from the date of signature. I understand that I may cancel this request with a written notification, but it will not affect any information released prior to the cancellation. I understand that the information used or disclosure may be subject to re-disclosure by the person or facility receiving it and would then no longer be protected by this release. I understand the medical provider to whom this authorization is furnished may not condition its treatment of me on whether or not I sign the authorization.
Signature of Patient

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Date

MonthDayYear
Date
Should be Empty:

Authorization for RELEASE of Medical Records