Authorization for Release of Medical Records - Cardiac Surgery

Department of Cardiac Surgery

I, _________________________ [Patient Name], DOB: //____, hereby authorize:

Release From:

• Current Healthcare Provider/Facility: ________________________
• Address: ________________________________________________
• Phone: _________________ Fax: _________________

Release To:

[Hospital Name] Department of Cardiac Surgery

• Address: ________________________________________________
• Phone: _________________ Fax: _________________

Information to be Released (check all that apply):

□ Complete Medical Record □ Cardiac Catheterization Reports □ Echocardiogram Reports □ Stress Test Results □ EKG/ECG Reports □ Laboratory Results □ Cardiac Imaging (CT/MRI) □ Progress Notes □ Other: ________________________________________________

Purpose of Release:

□ Continuing Medical Care □ Personal Use □ Insurance □ Legal Purposes □ Other: ________________________________________________

Authorization Period:

This authorization is valid for 90 days from the date of signature unless otherwise specified: ____________

Understanding and Rights:

• I understand that I may revoke this authorization at any time by notifying the providing organization in writing.
• I understand that any release which was made prior to my revocation in compliance with this authorization shall not constitute a breach of my rights to confidentiality.
• I understand that I may be charged a reasonable fee for copying medical records.
• I understand that my treatment cannot be conditioned on whether I sign this authorization.

Signature: _________________________ Date: //____

If signed by person other than patient: Name: _________________________ Relationship: _________________

For Office Use Only:

Received By: ______________ Date: //____ Processed By: _____________ Date: //____