Medical Record Release Form
Patient Information
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Organization to Release Information (from)
HealthCare Office / Provider name
Office
First Name
Last Name
Office Name / Location
*
Phone Number
Format: (000) 000-0000.
Fax Number
Address
Street Address
EMAIL ADDRESS
City
State / Province
Postal / Zip Code
Release Records To: HealthCare Provider /Physician /Self
Attention To or Patient Name
*
First Name
Last Name
Organization
*
Location or Myself
Street Address & Email address
PHYSICAL ADDRESS
Patient EMAIL address
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
Fax
Fax Number ONLY
Release Details
I, the patient, authorize and request the disclosure of all protected information I select below full and complete.
*
All medical records with every page included.
All physical, occupational and rehab requests, consultations and progress notes.
All laboratory, histology, cytology, pathology, immunohistochemistry records and specimens; radiology records and films including CT scan, MRI, MRA, EMG, bone scan, nerve conduction study, echocardiogram and cardiac catheterization results, videos/CDs/films/reels and reports.
All pharmacy/prescription records including NDC numbers and drug information handouts/monographs.
Other
Disclosed Purpose(s) of Protected Health Information
I, the patient, agree with the following statements:
*
I understand the information to be released or disclosed may include information relating tosexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), and alcohol and drug abuse. I am giving my consent to release or disclosure this type of information.
I understand this authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records of 42 CFR 2.31, the restrictions of which have been specifically considered and expressly waived.
I understand I have a right to revoke this authorization in writing at any time, except to the extentinformation has been released in reliance upon this authorization.
I understand the information released in response to this authorization may be re-disclosed to otherparties.
I understand my treatment or payment for my treatment cannot be conditioned on the signing of thisauthorization.
I understand any facsimile, copy or photocopy of the authorization shall authorize me to release the recordsrequested herein.
I understand this authorization shall be in force and effect until two years from date ofexecution at which time this authorization expires.
I understand if I want a printed copy there will be a cost per page. If mailed there will be an additional charge
Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
Should be Empty: