Medical Records Release Form

MEDICAL RECORDS RELEASE FORM
PATIENT IDENTIFICATION
Patient Full Name
Date of Birth

MonthDayYear
Date
Email Address
example@example.com
Social Security Number
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
AUTHORIZATION FOR USE OR DISCLOSURE
By signing this document, I, the above-named, hereby grant permission for the use or disclosure of my health information as outlined below. I understand that this information may include records maintained by the healthcare provider concerning my physical or mental health or condition, treatment received, and billing records related to my healthcare.

I understand that unencrypted e-mail is not secure - that means it could be intercepted and seen by others; in addition, I understand that there are other risks with unencrypted e-mail including misaddressed/misdirected messages; e-mail accounts that are shared; messages forwarded to others; and messages stored on portable devices having no security. By choosing to receive My Health Information by unencrypted e-mail, I am acknowledging and accepting these risks.

I understand there may be a fee for a copy of My Health Information. I understand that all fees will be in compliance with applicable law. I agree to pay this fee. Maryland law (Health General Sec. 4-304) allows physicians to charge patients (or the patient's "personal representative") a fee for copying medical records. The charges may be adjusted annually for inflation. Effective immediately, the fee remains as stated: A fee for copying not to exceed $0.76 for each printed page and $0.57 per digital page of the medical record; The actual cost of postage and handling; Preparation fee of $22.88, if the records are sent to another provider. The federal HIPAA regulations do not allow a charge for a preparation fee for records provided directly to the patient; A provider may not refuse to provide the records because of unpaid fees for medical services.
Request Applicable Date Range:
From: blanks* To: blank*
Type of Authorization*

Comprehensive Disclosure: I authorize the disclose of all my health-related information.Partial Disclosure: I authorize the disclosure of only the following health-related information:Other
If Partial Disclosure, please select from the following:*

Complete record Progress notes Applicable Date Range: Indicate the date range for which health information is relevant:Abstract (face sheet, history and physical, discharge summary, consult)DiagnosesPhysical Therapy notesProgress notesNot Applicable
AUTHORIZED RECIPIENT INFORMATION

I designate the following individual or entity to receive the health information specified:
Name of Authorized Party*
Relationship to Patient if applicable*
Organization if applicable*
Fax Number*
Email Address*
example@example.com
Address*
I wish to receive the records the following way:*

Printed and mailed to that authorized address abovePrinted and picked up from the clinic's font deskEmailed to the authorized email address above
I affirm that the Authorized Party named above is permitted to receive the health information as I have specified. This authorization does not permit further disclosure to additional parties unless specified and consented to by me in writing.
The purpose for which I am authorizing disclosure: General healthcare operations Other (Please specify):

This authorization shall remain valid until:

Iunderstand that I have the right to revoke this authorization at any time by submitting written notice to:
PURPOSE OF DISCLOSURE
General healthcare operationsPayment or billingLegal or insurance mattersOther
EXPIRATION AND REVOCATION
This authorization shall remain valid until:*

A specific event occursDate
I understand I have the right to revoke this authorization at any time by submitting written notice to:
Name/Department
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I acknowledge that: . I am aware that I may refuse to sign this authorization. I am entitled to receive a copy of this authorization. I may inspect or copy the authorized information. My refusal will not affect my ability to obtain treatment except in cases where the authorization is required by law.
RIGHTS AND ACKNOWLEDGMENTS
I acknowledge that:*

I have read an understand my rights under HIPAA.I am aware that I may refuse to sign this authorization.I am entitled to receive a copy of this authorization.I may inspect or copy the authorized informationMy refusal will not affect my ability to obtain treatment except in cases where the authorization is required by law
SIGNATURES

This authorization shall remain valid until:
Signature of Patient*
Date*

MonthDayYear
Date
Print Name*
If the patient is unable to sign, a legal representative may sign below:
Reason for patients inability to sign
Signature of Representative
Date

MonthDayYear
Date
Print Name
Relationship to Patient:

ParentSpouseGuardian
Other Please specify
Should be Empty:

MEDICAL RECORDS RELEASE FORM

PATIENT IDENTIFICATION

AUTHORIZATION FOR USE OR DISCLOSURE

PURPOSE OF DISCLOSURE

EXPIRATION AND REVOCATION

RIGHTS AND ACKNOWLEDGMENTS

SIGNATURES