Medical Records Release

Medical Records Release
Patient name

First NameMiddle NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
In case we have questions about your requestFormat: (000) 000-0000.
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Records to release (check all that apply)
If "Other," describe
Purpose of release
How should we deliver the records?
Needed by (date)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Facility or physician name
Facility address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Room / floor / suite
Facility phone
Please enter a valid phone number.Format: (000) 000-0000.
Facility fax
Please enter a valid phone number.Format: (000) 000-0000.
Printed name of patient (or representative)
Relationship to patient
If signing as a representative
How should we confirm?
Email address
example@example.com
Confirmation consent
I authorize the custodian of records of Urology Associates of Cape Cod, PC to disclose the health information selected above. I understand: (1) this authorization is voluntary, and refusing to sign does not affect my treatment, payment, or eligibility for benefits; (2) information disclosed under this authorization may be redisclosed by the recipient and may no longer be protected by federal privacy law; (3) I may revoke this authorization at any time by written notice to the practice, except to the extent it has already been acted upon; (4) this authorization expires one (1) year from the date signed, unless I specify an earlier date; (5) I have the authority to sign this document, and no order or claim restricts my ability to authorize this disclosure; (6) under HIPAA and Massachusetts law, the practice may take up to 30 days to fulfill a records request.
Signature of patient (or representative)
Date signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: