Medical Records Release
Homedica House Calls
Patient Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
SSN
*
I understand:
I may refuse to sign this authorization, and it is strictly voluntary.
My treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this
authorization.
I may revoke this authorization at any time in writing to the provider authorized to release the
protected health information but if I do, it will not have any effect on any actions taken prior to
receiving the revocation.
If the requester or receiver is not a health plan or health care provider, the released information may
no longer be protected by federal privacy regulations and may be disclosed.
I have the right to receive a copy of this form after I sign it.
Who will be signing the medical release form?
Patient
Responsible Party
Signature of Patient
*
Date
*
/
Month
/
Day
Year
Date
Responsible Party Name
*
Relationship to Patient
*
Patient Responsible Party Signature (if necessary)
*
Date
*
/
Month
/
Day
Year
Date
Preview PDF
Submit
Should be Empty: