Authorization for Release of Medical Records - Cardiology Department

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________ Email: _________________________ Medical Record #: __________

Records to be Released From

Facility Name: __________________ Phone: ___________________ Address: _______________________ Fax: _____________________

Records to be Released To

Facility/Person: _________________ Phone: ___________________ Address: _______________________ Fax: _____________________

Information to be Released

(Check all that apply)

• Complete Medical Record
• Cardiology Reports
• ECG/EKG Results
• Stress Test Results
• Echocardiogram Reports
• Cardiac Catheterization Reports
• Holter Monitor Results
• Lab Results
• Progress Notes
• Other: ___________________

Date Range

From: _____________ To: _____________

Purpose of Release

• Continuing Care
• Personal Use
• Insurance
• Legal
• Other: ___________________

Authorization & Understanding

I understand that:

1. This authorization expires one year from the date signed
2. I may revoke this authorization at any time in writing
3. Information disclosed may be subject to redisclosure
4. Treatment is not conditioned upon signing this authorization

Signature: _____________________ Date: ___________________

(If signed by person other than patient) Relationship to Patient: ___________________________________

For Office Use Only

Request processed by: _____________ Date: _________________ ID verified: [ ] Yes [ ] No Method: _________________________