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

Zip Code
Date of Birth*

MonthDayYear
Daytime Phone Number*
Format: (000) 000-0000.
Social Security Number*

Purpose of Disclosure
Graduation to OBGYN (Pregnancy)Continuity of Care (Referring Physician/Treating Provider)Personal UseTransfer of Care to Another Fertility Clinic
Before You Transfer Your Care

We truly appreciate the opportunity to have been part of your care. It means a great deal that you chose our clinic and placed your trust in our team.

We understand that care decisions evolve, and we are happy to assist with transferring your records. However, if you are open to it, we would sincerely value the opportunity to connect with you before finalizing your transfer. Every patient is important to us, and we are always available to discuss any questions, concerns, or changes in circumstances.

Our clinic is proud of the strong outcomes we consistently achieve and our commitment to individualized, evidence-based care. We would welcome the chance to review your treatment plan together and explore any options that may continue to support your goals.
Yes, I would like to speak with a team memberNo, Continue with Medical Records Request

Organization Requesting Information
Name of Person or Organization Requesting Information*
Address*

Street Address

Street Address Line 2

CityState / Province

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

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
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.
I have read and understand my right to revoke authorization.

Authorization and Signature
Speak to a Team Member
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.
By submitting this form, I hereby authorize Brown Fertility to contact me via email to discuss my purpose of disclosure. I understand that opting into this discussion is a separate service and does not fulfill my request for medical records. I acknowledge that I must still complete the records release form to obtain my health information.
Name of Patient*

First NameLast Name
Name Of Parent, Guardian or Legal Representative

First NameLast Name
Relationship To Patient
Email*

Confirmation EmailConfirm email
Records Are Needed By

MonthDayYear
Date
Electronic Format (Email)FaxMailPatient Will Pick Up
Fax Number*
Please enter a valid fax number.Format: (000) 000-0000.
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
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

Purpose of Disclosure

Purpose of Disclosure

Organization Requesting Information

Organization Providing Information

Information To Be Disclosed

Special Authorization To Disclose Super-Confidential Information

Right to Revoke Authorization

Authorization and Signature

Speak to a Team Member