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.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person/Organization to Release Information
HealthCare Provider/Physician/Medicare Contractor Name
Title
First Name
Last Name
Organization Name
Phone Number
Fax Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person/Organization to Receive Information
Name
First Name
Last Name
Organization
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Fax
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 disability, Medicaid or Medicare records including claim forms and record of denialof benefits.
All employment, personnel or wage records.
All autopsy, laboratory, histology, cytology, pathology, immunohistochemistry recordsand specimens; radiology records and films including CT scan, MRI, MRA, EMG,bone scan, myleogram; nerve conduction study, echocardiogram and cardiaccatheterization results, videos/CDs/films/reels and reports.
All pharmacy/prescription records including NDC numbers and drug informationhandouts/monographs.
All billing records including all statements, insurance claim forms, itemized bills, andrecords of billing to third party payers and payment or denial of benefits
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.
Date
-
Month
-
Day
Year
Date
Signature
Submit
Submit
Should be Empty: