Medical Record Release Request_v4

STAT

ROUTINE
STAT

STAT
Name of Patient:*
Date of Birth:*
Social Security Number:
Phone Number:*
Please enter a valid phone number.
RECORD HOLDER INFORMATION:
Who is the record holder?*

Excel Spine CenterOther:
Office or Doctor's Name:
Address:
City, State, Zip:
Phone Number:
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
RECORDS MAY BE RELEASED TO:
Who should we send the records to?*

Excel Spine CenterOther:
Name:
Address:
City, State, Zip:
Phone Number:
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Email:
example@example.com
SEND RECORDS BY:
Secure EmailFaxMail (Please note, mailed requests will be a $15.00 charge plus $0.25 per page)
TYPE OF RECORDS TO BE SENT:
Medical RecordsOperative ReportsLabs/EKGX-rays/MRI/CTPhysical TherapyBillingInjection ReportsOther
DATES OF SERVICE:
From:

MonthDayYear
Date
To:

MonthDayYear
Date
USE OF INFORMATION:
Continuing Medical CareTransfer of CareSecond OpinionPersonalInsuranceLegalOther
Duration: This authorization is valid for one year from the date next to my signature unless noted here:

MonthDayYear
Date
Additional Copy

I further understand that I have the right to receive a copy of this authorization upon my request.

Re-Disclosure

A statement that protected health information used or disclosed pursuant to the authorization may or may not be subject to re-disclose by the recipient and thus no longer protected by the Privacy Rule.

Revocation

This authorization is also subject to written revocation by the undersigned at any time between now and the disclosure of the information by the disclosing party. Written revocation will be effective upon receipt but will not be effective to the extent that the requester is specifically required or permitted by law.

Explanation

I understand that my treatment is no way conditioned on whether I sign the authorization or not and that I may refuse to sign the authorization.

Patient Billing

I understand that I will be charged $15.00 plus $0.25 per page for mailed requests.
SIGNATURE:
Printed Name:*
Signature:*

Clear
Date/Time:*
If signed by other than patient, indicate relationship to patient:
Witness Signature:

Clear
Date/Time:
Should be Empty:

RECORD HOLDER INFORMATION:

RECORDS MAY BE RELEASED TO:

SEND RECORDS BY:

TYPE OF RECORDS TO BE SENT:

DATES OF SERVICE:

USE OF INFORMATION:

SIGNATURE: