Release of Medical Records

Release of Medical Records

This authorization is for the release of medical information.
Patient Information
Your Name*

First NameMiddle NameLast Name
Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Daytime Phone Number*
Social Security Number*

Organization Providing Information
Name of Person or Organization Releasing Information*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Organization Requesting Information
Name of Person or Organization Releasing Information*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Special Authorization To Disclose Super-Confidential Information
ALCOHOL/DRUG/INFECTIOUS DISEASE/MENTAL HEALTH RECORDS are protected by Federal Regulation 42 CFR, Part 2. Release of such records requires specific consent. I hereby grant such specific consent as initialed below.

I UNDERSTAND that these records are protected under federal and state law and cannot be disclosed without my written consent unless otherwise provided by law. I further understand that the specific type of information to be disclosed may, if applicable, include diagnosis, prognosis, and treatment for physical and/or mental illness including treatment of alcohol or substance abuse, sexually transmitted diseases, acquired immune deficiency syndrome (AIDS), or human immunodeficiency virus (HIV) infection.

AS PART OF THE MEDICAL RECORDS CHECKED ABOVE, THE FOLLOWING INFORMATION WILL BE RELEASED UNLESS STRICKEN:
- HIV/AIDS related information and/or records
- Mental Health information and/or records
- Sexually transmitted diseases
- Drug/alcohol diagnosis, treatment or referral information
Consent*

By checking this box, I agree to this special authorization.

Right to Revoke Authorization
I MAY REVOKE THIS AUTHORIZATION AT ANY TIME, IN WRITING, BEFORE THE INFORMATION HAS BEEN RELEASED. I FURTHER UNDERSTAND THAT I HAVE A RIGHT TO RECEIVE A COPY OF THIS AUTHORIZATION UPON REQUEST. I HEREBY RELEASE BROWN FERTILITY FROM ANY AND ALL LEGAL LIABILITY THAT MAY ARISE FROM THE RELEASE OF THIS INFORMATION TO THE PARTY NAMED ABOVE.
Authorization*

I have read and understand my right to revoke authorization.

Authorization and Signature
I hereby authorize the use of disclosure of my individually identifiable health information as described below. I understand that this authorization is voluntary. I understand that treatment, payment, enrollment or eligibility of benefits may not be conditioned on my signing this authorization. I further understand that if the organization authorized to receive the information is not a health plan or health care provider, the released information could potentially be disclosed and may no longer be protected by federal privacy regulations. Therefore, I release Brown Fertility from all liability arising from this disclosure of my health information.

I understand and agree that I am financially responsible for the following fees associated with my request: copying charges and postage related to the production of my information. For patients and governmental entities: 1.00 per page for the first 25 pages and 25¢ per page for each page in excess of the first 25 pages. For other entities: up to $1.00 per page for each page copied, in accordance with Florida Administrative Code 64B8-10.003.

BY SIGNING THIS AGREEMENT, I ACKNOWLEDGE THAT I HAVE CAREFULLY READ, UNDERSTAND AND AGREE TO THE ABOVE TERMS AND CONDITIONS.
Name of Patient*

First NameLast Name
Email
example@example.com
Name Of Parent, Guardian or Legal Representative

First NameLast Name
Relationship To Patient
Records Are Needed By

MonthDayYear
Date
Send By*

FaxMailPatient Will Pick UpElectronic Format (EMR)
Fax Number
Privacy Policy*

By checking this box, I confirm that I have read and understand the Privacy Policy provided by Brown Fertility at www.brownfertility.com/privacy-policy
Submission Consent*

By checking this box, I agree to Brown Fertility's use of this information.
Signature*

Clear
To sign left click and drag mouse or use your finger or stylus if touch screen
Please verify that you are human.*
Should be Empty:

Release of Medical Records

Patient Information

Organization Providing Information

Organization Requesting Information

Information To Be Disclosed

Special Authorization To Disclose Super-Confidential Information

Purpose of Disclosure

Right to Revoke Authorization

Authorization and Signature