Medical Record Release Form
*Please use this form if you are requesting Stark Medical Release your records to another person/organization*
Patient Information
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@gmail.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person/ Organization to RECEIVE Information
Organization Name/ Name
*
Phone Number
*
Format: (000) 000-0000.
Fax Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person/Organization to RELEASE Information
STARK MEDICAL
Brandan Stark DO
Yvette Stark NP
PH: 530-514-0904
FAX: 866-493-2923
Release Details
I, the patient, authorize and request the disclosure of all protected information I select below full and complete.
*
All of my medical-related information.
Other
Disclosed Purpose(s) of Protected Health Information
*
Continue Care
Other
I, the patient, agree with the following statements:
*
I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), and alcohol and drug abuse. I am giving my consent to release or disclose this type of information.
I understand I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization.
I understand the information released in response to this authorization may be re-disclosed to other parties.
I understand my treatment or payment for my treatment cannot be conditioned on the signing of this authorization.
I understand any facsimile, copy or photocopy of the authorization shall authorize me to release the records requested herein.
I understand this authorization shall be in force and effect until two years from date of execution at which time this authorization expires.
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
*
Submit
Submit
Should be Empty: