Authorization for Release of Medical Records - Geriatric Care

Patient Information

• Full Name: _________________________ Date of Birth: //___
• Previous Names: _____________________ SSN (last 4): XXX-XX-_____
• Address: _____________________________ Phone: ________________

Records to be Released From

• Provider/Facility: ____________________
• Address: ____________________________
• Phone: _____________ Fax: ____________

Records to be Released To

• Provider/Facility: ____________________
• Address: ____________________________
• Phone: _____________ Fax: ____________

Information to be Released

• Complete Medical Record
• Last 2 Years Only
• Specific Date Range: //___ to //___
• Specific Information:
  • Progress Notes
  • Lab Results
  • Imaging Reports
  • Medication Lists
  • Vaccination Records
  • Care Plans
  • Cognitive Assessments
  • Other: ______________

Sensitive Information

I specifically authorize the release of records relating to:

• Mental Health Treatment
• Substance Use Treatment
• HIV/AIDS Information
• Genetic Testing

Purpose of Release

• Continuing Medical Care
• Personal Records
• Legal Purposes
• Insurance
• Other: ______________

Understanding and Signature

I understand that:

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

Patient/Legal Representative Signature: ___________________ Date: //___

If Legal Representative, state relationship: _______________

For Office Use Only

Request processed by: _________________ Date: //___ ID Verified: [ ] Yes [ ] No Method: _____________