Authorization for Release of Medical Records

Patient Information

Full Name: _________________________________ Date of Birth: //___ Address: _____________________________________ Phone: (____) -_ Email: ______________________________________ SSN (last 4): XXX-XX-_____

Records To Be Released From

Practice Name: ________________________________ Provider Name: ________________________________ Address: _____________________________________ Phone: () -_ Fax: () -_

Records To Be Released To

Recipient Name: _______________________________ Organization: ________________________________ Address: _____________________________________ Phone: () -_ Fax: () -_

Information to be Released (Check all that apply)

□ Complete Medical Record □ Office Visit Notes □ Diagnostic Imaging Reports □ X-rays/MRI/CT Images □ Laboratory Results □ Physical Therapy Notes □ Operative Reports □ Other: ____________________________________

Date Range

From: //___ To: //___ □ All dates

Purpose of Release

□ Continuing Care □ Personal Use □ Insurance □ Legal □ Other: ____________________________________

Authorization

I understand that:

• This authorization is valid for 90 days from the date of signature
• I may revoke this authorization at any time in writing
• Re-disclosure of my medical records by recipients is not protected under HIPAA
• I am entitled to a copy of this authorization
• A copy of this authorization is as valid as the original

Signature: ___________________________ Date: //___

If signed by representative: Name: ______________________________ Relationship: _______________

For Office Use Only

Request received: //___ Processed by: ___________________ Date completed: //___ ID verified: □ Yes □ No