Authorization to release medical records

Patient's Full Legal Name:

NO NICKNAMES PLEASE

Date of Birth:

Patient Address:

Street Address

Street Address Line 2

CityState

Zip Code

Phone number:

Format: (000) 000-0000.

Facility Name:

Facility Address:

Street Address

Street Address Line 2

CityState

Zip Code

Fax Number:

To ensure your provider gets reports, please provide the fax number to the facility receiving your records. Failure to do so, may cause a delay in them receiving reports. If a phone number is put in place, your facility will not receive reports.Format: (000) 000-0000.

Release type:

Treatment Dates or timeframe (be specific):

Please note we only keep records up to 10 years per South Carolina Law, under S.C. Code Regs. 61-16.1107

Type of exams being released:

Purpose for release

PLEASE READ:

Please note most physicians offices don't have disc reading capabilities and will not accept images. When in doubt, give them a call and ask if they need images or just need the radiology report before submitting your request with us.

If you are needing images shared- It will be up to the ISC medical records department discretion on how those images are shared. If we have electronic image sharing capabilities, we will do so. If not, the images will be placed on a disc and will be mailed via USPS (snail mail). Once it is in the mail we do not have any tracking capabilities or have any control on delivery date.

Common local facilities/affiliates we electronically share images with:

Roper
East Cooper/Novant
MUSC
Trident
Summerville Medical Center

PATIENT RIGHTS: I understand that:

I have the right to revoke this authorization at any time. The revocation must be made in writing and presented or mailed to the Health Information Management department. Revocation will not apply to information that has already been disclosed in response to this authorization. Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on whether I sign this authorization. Any disclosure of information carries with it the potential for unauthorized redisclosure, and the information may not be protected by federal confidentiality rules. I understand that the information in my health record may include information relating to sexually transmitted disease (STD), acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV It may also include information about behavioral or mental health services, and treatment of alcohol or drug abuse.

Patient Signature:

Date of signature:

Date

AUTHORIZATION TO RELEASE MEDICAL RECORDS

PATIENT INFORMATION

RELEASE RECORDS TO: