Authorization for Release of Medical Records - Concierge Practice

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________

Records To Be Released From

Practice Name: _________________ Physician: _____________________ Address: _______________________ Phone: __________ Fax: _________

Records To Be Released To

[Practice Name] Concierge Medicine Physician: _____________________ Address: _______________________ Phone: __________ Fax: _________

Information to be Released

(Check all that apply)

□ Complete Medical Record □ Lab Results □ Imaging Reports □ Vaccination Records □ Medication History □ Last [__] years of records only □ Other: _______________________

Purpose of Release

□ Transitioning to Concierge Care □ Continuation of Care □ Personal Records □ Other: _______________________

Authorization

I understand that:

1. This authorization is valid for 90 days from the date of signature
2. I may revoke this authorization at any time in writing
3. This release may include sensitive information (separate initials required):
   • Mental Health Records: _____ (initial)
   • HIV/AIDS Information: _____ (initial)
   • Substance Use Records: _____ (initial)

Patient Signature: ______________ Date: __________

Witness Signature: _____________ Date: __________

This form complies with HIPAA Privacy Rule requirements Form version: [Date]