Release of Information Form

MEDICAL RECORDS RELEASE FORM
PLEASE NOTE: IF YOU ARE REQUESTING MEDICAL RECORDS FOR YOURSELF OR TO TAKE TO A PHYSICIANS OFFICE, UCC CHAGED .60 PER PAGE PAYABLE PRIOR TO MEDICAL RECORD RELEASE.

If you are establishing care with another Physician or Endocrinologist , the best way for them to obtain your records is to fax a request to 702-476-4949 and we will send directly to the physicians office and there is no charge for this.
By signing below I have acknowledged the above statement of charges*

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Name*

First NameLast Name
Birth Date*

MonthDayYear
Last 4 SSN*
Attach a Picture ID Here*

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Phone Number*

Area CodePhone Number
Email*
example@example.com
I AUTHORIZE UNITED CRITICAL CARE TO RELEASE MY MEDICAL RECORDS TO*

My DoctorMyself
Name of facility/provider to SEND records to*
Fax number of facility/provider to SEND records to*

Area CodeFax Number
Phone number of facility/provider to SEND records to*

Area CodePhone Number
MYSELF ( PLEASE PROVIDE WHERE AND HOW TO SEND)*
I AUTHORIZE RELEASE OF THE FOLLOWING MEDICAL RECORDS ( CHOOSE ONE)*

COMPLETE MEDICAL RECORD including information and copies of records relating to the history, diagnosis, treatment or services rendered to me in connection with any condition or disease. This includes permission to release potentially sensitive information which may include information concerning my treatment of mental illness, HIV, alcoholism, drug use/dependency, venereal disease, sexual assaults, abortion, illegitimacy birth, communications to social workers and/or psychotherapists, psychologists, if any.PARTIAL MEDICAL RECORD
PARTIAL INFORMATION THAT MAY BE RELEASED*

Medical ConsultationsDischarge RecordsFinancial RecordsImaging ReportsOperation ReportsPsychological TestsEmergency RecordsMedical History & Physical ExamLaboratory & Pathology ReportsProgress NotesProcedure ReportsSpecialized Tests ( ie: EKG's, Sleep Studies, Pulmonary Tests)ALL RECORDS ON FILEOther
PURPOSE OF DISCLOSURE*

Continued Medical CareLegal PurposesInsurance PurposesPersonal InterestOther
I RELEASE UNITED CRITICAL CARE LUNG-SLEEP MEDICINE Inc. and the recipient/discloser listed above and any of their providers and staff from all responsibility and liability that may arise from this authorization. I may withdraw this authorization at any time by giving a written notice to United Critical Care Lung-Sleep Medicine Inc , provided that I do so in writing and to the extent that you may have already disclosed the information in reliance on this authorization. I MAY ALSO INDICATE BELOW THE DATE THIS RELEASE EXPIRES
THIS RELEASE SHALL REMAIN IN EFFECT INDEFINITELY UNTIL REVOKED IN WRITING*

YESNO
THIS RELEASE WILL EXPIRE OF THE FOLLOWING DATE*

MonthDayYear
Date
Signature*
Date*

MonthDayYear
Date
Should be Empty:

MEDICAL RECORDS RELEASE FORM