Authorization to Release and Disclose Patient information
Renew ENT & Hearing Center | Renew Plastic Surgery
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I want to...
*
Request a copy of my own records
Have Renew request a copy of my records from another facility
Have Renew send my records somewhere else
I would like to have my records released via...
*
Paper/Mailed
Fax (for patient care only)
Electronic (emailed)
Verbal
Patient Portal
Other method (ex. "imaging disc")
I need my records by...
/
Month
/
Day
Year
Note: Please allow 5-7 business days for processing.
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Patient Information
Name
*
First and Last Name.
Date of Birth
*
/
Month
/
Day
Year
Phone
*
Street Address
*
Please omit punctuation and special characters.
City
*
State
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
*
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Who has the information you want released?
Name
*
Facility Name or First and Last Name.
Phone
*
Fax
Fax.Duplicator
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Street Address
Please omit punctuation and special characters.
City
State
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
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Who is the receiving party?
Where do you want the information to be sent?
Name
*
Facility Name or First and Last Name.
Phone
*
Fax
Email address
Street Address
Please omit punctuation and special characters.
City
State
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
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Information to be released
What information do you want sent? Please select all that apply
I would like to release my...
*
Billing Records
Audiology Tests
Radiology Reports
Laboratory Reports
All Records
Progress/Clinic Notes
(Optional) I only want to release my information related to...
A specific date range
A specific diagnosis
Start Date
/
Month
/
Day
Year
Date
End Date
/
Month
/
Day
Year
Date
Only release records related to this diagnosis:
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Purpose of the Release
Why is the information needed?
Purpose of the Release
*
Continuing Care
Transfer of Care
Litigation
Insurance Application
Personal Use
Other
I would like this form to be valid...
*
for as long as possible (1 year from the date I sign)
Until a specified date (up to 1 year after the date I sign)
I would like this authorization to expire on...
/
Month
/
Day
Year
Note: This form will be valid for no more than 1 year past the signature date.
This authorization can be canceled in writing at any time. A cancellation will not change releases that happen before the
cancellation. Please ask us how to cancel this authorization.
A photo copy of this authorization will be treated in the same way as an original.
Released records may include records that were received from other organizations if these records have been filed in
the record maintained about you.
Redisclosure of your information by the person or organization who receives your records under this authorization
cannot be prevented and may not be covered by state and federal privacy protections after it is released. By signing this
authorization you release Renew from any and all liability resulting from a redisclosure by the recipient.
Your signature indicates that you have read and understand the forms and authorize the release of your information.
Today's Date
*
/
Month
/
Day
Year
Date
Signature
*
Relationship
*
If you are the patient, the relationship is "self"
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