Medical Records Release and Consent Form

Release of Information Consent Form
Do you want Morrison Clinic to release information or send Morrison Clinic medical records to a 3rd party? *
Patient Information
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Patient Phone Number*
Please enter a valid phone number.
Patient Email Address*
example@example.com
PATIENT OR LEGAL REPRESENTATIVE'S AUTHORIZATION FOR MORRISON CLINIC TO RELEASE INFORMATION
Do you authorize Morrison Clinic located at 5300 Town and Country Blvd Suite 155 Frisco, TX 75034 to release your information? *
Do you authorize Morrison to release your verbal or written information? *
Would you like Morrison Clinic to fax or email your records?*
Do you authorize Morrison Clinic to email your records?*
Do you authorize Morrison Clinic to fax your records to you or a 3rd party?*
RECEIVER OF YOUR MEDICAL INFORMATION
Type in the name of the recipicient, facility, clinician, or person you want Morrison Clinic to send your records to *
Type in the email address of the receipient*
example@example.com
Type in the fax number of the receipient*
Type in the phone number of the receipient*
Purpose of Release of Verbal Information *
Type in purpose of verbal release of information*
Purpose of Transfer of Written Records*
Type in purpose of transfer of wrtitten records*
Written Information to be Released*

Psychiatric EvaluationPsychiatric Evaluation with last several progress notes and psychological testingMedication RecordProgress NotesPsychological TestingWork Accommodations Paperwork and supporting documents like progress notes and lettersSchool Accommodations Paperwork and supporting documents like progress notes and lettersOther
Are you requesting for your medical records to be sent from Morrison Clinic to another medical provider?*
There is a $25 administrative fee to send your Morrison Clinic medical records to another provider. Would you like to proceed? *
Your signature below authorizes for your payment card on file to be charged a $25 processing fee for medical records to be sent from Morrison Clinic to another provider.*

Clear
Patient/Legal Representative Consent:

I have read and understood this authorization for the transfer of medical information and/or records and voluntarily consent to its terms.
- I understand that incomplete forms will be null and void; no exceptions.
- I understand that specific information to be disclosed may include history of Drug or Alcohol Abuse or Mental Health Treatment, information concerning communicable diseases such as Human Immunodeficiency Virus (HIV), and Immune Deficiency Syndrome (AIDS), laboratory test results, treatment progress, and any other such related information.
- I understand that the information released is for the specific purpose stated above. Any other use of this information without the written consent of the patient is prohibited.
- I understand that a revocation is not effective to the extent that the practice has relied on this authorization in its actions. Also, a revocation is not effective if this authorization was obtained as a condition of obtaining insurance coverage, as other law provides the insurer with the right to contest a claim under the policy or the policy itself.
- I further authorize that a photocopy of this authorization is acceptable as an original.
- I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal HIPAA privacy regulations.
- The practice will not condition my treatment, payment, and enrollment in a health plan or eligibility for benefits on whether I provide authorization for the requested use or disclosure.
- This authorization will expire 1 year from the date of this signature.
- I understand that I have the right to revoke this authorization, in writing, at any time by sending written notification to: Privacy Officer: Fax: (847) 787-1437
Is the person signing this form the patient?*
Description of the Personal Representative's Authority*
Legal Documentation of Personal Representative's Authority*

Cancelof
Date*

MonthDayYear
Date
Name of Patient or Personal Representative *
Signature of Patient or Personal Representative *

Clear
Should be Empty:

Release of Information Consent Form

Patient Information

PATIENT OR LEGAL REPRESENTATIVE'S AUTHORIZATION FOR MORRISON CLINIC TO RELEASE INFORMATION

RECEIVER OF YOUR MEDICAL INFORMATION