Authorization for Release of Medical Records

Patient Information

Name: _________________________________ Date of Birth: //___ Address: _______________________________ Phone: (__) -

Release Information From

Facility/Provider Name: __________________ Address: _______________________________ Phone: () - Fax: () -

Release Information To

Facility/Provider Name: __________________ Address: _______________________________ Phone: () - Fax: () -

Information to be Released

• Complete Medical Record
• Office Visit Notes
• Operative Reports
• Colonoscopy Reports
• Pathology Reports
• Laboratory Results
• Imaging Reports
• Other: ____________________________

Date Range

From: //___ To: //___

Purpose of Release

• Continuing Medical Care
• Insurance
• Legal
• Personal Use
• 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
• Once information is released, the facility cannot prevent its redisclosure
• I am entitled to a copy of this authorization
• A copy of this authorization is as valid as the original

Signature: ______________________________ Date: //___ Relationship to Patient (if not self): ______________________________

For Office Use Only

Request processed by: _________________ Date: //___ ID verified: □ Yes □ No Method: _________________