Records Release

Authorization for the Use/Disclosure of Protected Health Information-

Records Release

This form cannot be used for the re-release of confidential information provided to the doctor's office by other individual or agencies. Such requests should be referred to the original individual or agency.
Patient name*
Birth Date*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Patient address*
Street, City, State, Zip
Release Information FROM:*
Previous PCPs, Specialists, Hospital systems, urgent cares.
Release Information TO: Focus Family Medicine
Release Information TO: Dr. Jennifer Lane at Focus Family Medicine
Fax: 615-622-8683 Phone: 615-819-4650
Email: hello@focus.sprucecare.com
357 Riverside Dr. #260, Franklin, TN 37064
The protected health information to be used or disclosed is as follows:*

Entire Medical RecordX-ray or other imaging reportsOffice NotesOther information (please describe)
This information is being disclosed for the following purpose:*

Continuity of careAt my requestOther
I understand the information to be released may include records related to behavior and/or mental health care, alcohol and drug abuse treatment, HIV/AIDS, and genetics. This authorization may be revoked at any time except to the extent that action has been taken in reliance upon it. Revocation must be made in writing to the provider/facility releasing the information. The provider/facility will not condition treatment on whether I sign the authorization. I may be charged for copies in accordance with the state law. Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal law.
Signature of Patient or Personal Representative*

Clear
Printed Name*
Patient phone*
Date*

MonthDayYear
Date
Should be Empty:

Release Information TO: Focus Family Medicine