Online Medical Records Release from Ebenezer to :

The undersigned hereby authorized the release of information contained in the medical records of:

Patient Name: (Only one name per form.)*

First NameLast Name

Patient Date of Birth*

Date

Address: (Please include City, State, & Zip)

Phone Number*

Area CodePhone Number

Release Records TO (Name of doctor/ Office releasing records to):*

Phone Number*

Area CodePhone Number

Fax Number *

Area CodeFax Number

The Medical record is needed for the following purpose:*

If selected 'Other' above, please specify below

Time period of:*

Information to be released:

The following specific portions of the medical records*

I, the undersigned, understand that I may revoke this authorization at any time, in writing, but the request shall remain valid until revoked or upon expiration of three hundred and sixty five (365) days, whichever occurs first except to the extent that action has been taken thereon. I understand that I am giving permission to release medical information, which may include treatment for physical and/or emotional illnesses, communicable diseases, alcohol or drug abuse treatments, and/or HIV, AIDS, OR AIDS-related information. I understand that authorization for the disclosure is voluntary, I can refuse to sign this authorization, and the healthcare provider will not condition treatment, payment, enrollment in any health plan or eligibility for benefits on the signing of an authorization, except as otherwise permitted by law. I understand that any disclosure of information carries with it the potential for re-disclosure and the information may no longer be protected under the Health Insurance Portability and Accountability Act of 1996. Your Healthcare Provider may charge you for the transfer of your records under Oklahoma State Law. EBENEZER HEALTHCARE SERVICES DOES NOT CHARGE FOR RECORDS FROM PHYSICIAN TO PHYSICIAN.

Requester Identification*

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Signature*

Date*

Medical Records Release Form