Authorization for Release of Medical Records

Patient Information

Full Name: _________________________________ Date of Birth: //___ Address: ___________________________________________________________ Phone: ________________________ Email: ______________________________

Release Information

Records Released From:

Provider/Facility Name: ____________________________________________ Address: ___________________________________________________________ Phone: ________________________ Fax: _______________________________

Records Released To:

Provider/Facility Name: ____________________________________________ Address: ___________________________________________________________ Phone: ________________________ Fax: _______________________________

Information to be Released

• Complete Medical Record
• Lab Results
• Imaging Reports
• Immunization Records
• Progress Notes
• Other (specify): _____________________________________________

Date Range: From //___ To //___

Purpose of Release

• Continuing Care
• Personal Records
• Insurance
• Legal
• Other (specify): _____________________________________________

Authorization & Understanding

• I understand that this authorization is valid for 12 months unless revoked in writing
• I understand that I may revoke this authorization at any time by notifying the providing organization in writing
• I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient
• I understand that my treatment cannot be conditioned on signing this authorization

Signature: _________________________________ Date: //___

If signed by person other than patient, state relationship and authority to do so:

For Office Use Only

Request received by: __________________ Date: //___ Request processed by: _________________ Date: //___