Dr. Scott: DCPP Authorization for Release of Medical Records

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
Medical Facility's Name*
"Medical Facility" indicates the name of the practice we are requesting records from.
Medical Facility Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical Facility Phone Number*
Please enter a valid phone number.
Medical Facility Fax*
We will fax your release to this number.
I authorize the above facility to release information from the record of:
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Date
To: Direct Care Physicians of Pittsburgh: Dr. Emily Scott 201 S. Highland Ave, Suite 101, Pittsburgh, PA 15206 Phone: (412) 219-4613 x2 Fax: (888) 860-4094
Reason for medical record request:*
Example: Transfer of care
Parts 1 and 2 must be completed to properly identify the records to be released.

1. Types of records to be released and approximate date(s) that apply. Check all that apply.
Types of records to be released.*

InpatientOutpatientEmergency Dept.Physician Office/Clinic
Beginning Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
I authorize the release of: (check all that apply) contained in the records indicated above.

Mental Health InformationDrug and Alcohol Infomration
2. Specific information to be released (check all that apply):*

ConsultsDischarge Summary/InstructionsLaboratory Reports/TestsMammography ReportEmergency Dept. ReportMedical History & Physical ExamMedication RecordsOperative ReportPhysician OrdersProgress NotesPsychiatric/Psychological EvalRadiology ReportPathology ReportEKG ReportOther
HIV-related information contained in the parts of the records indicated above will be released through this authorization unless otherwise indicated.

Do not release
I understand that this Authorization is effective for a period of 90 days from the date of the signature, unless otherwise specified below. No time frame may exceed one year after the date of signature. I understand that I have the right to revoke this authorization at any time by sending a written request to the entity/person I authorized above to release the information.
If applicable, specify other expiration date/event here

MonthDayYear
Date
Signature of Patient*

Clear
Date of Signature*

MonthDayYear
Date
(14 years of age or older may authorize release of mental health information. A minor can authorize release of drug & alcohol treatment information without parental consent)
(If applicable) Signature of Parent, Legal Guardian or Authorized Representative

Clear
Date of Signature

MonthDayYear
Date
(If applicable) Authorized Representative's relationship and authority to act on behalf of patient
Should be Empty:

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION