Authorization for Release of Medical Records - Neurology Department

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________ Email: _________________________ SSN (last 4): _____________

Records Release Authorization

I hereby authorize _____________________ [Current Provider/Facility] to:

• Release medical records TO
• Obtain medical records FROM

Provider/Facility: _________________________________________ Address: ________________________________________________ Phone: ______________________ Fax: _______________________

Information to be Released

• Complete Medical Record
• Neurological Examination Reports
• EEG Reports
• EMG/NCV Studies
• MRI/CT Reports
• Laboratory Results
• Treatment Plans
• Medication Records
• Other: ___________________

Date Range: From _____________ To _____________

Purpose of Release

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

Sensitive Information

I understand that these records may contain sensitive information. I specifically authorize the release of information relating to:

• Mental Health Records
• HIV/AIDS Testing & Results
• Substance Use Treatment

Understanding & Rights

• This authorization is valid for 12 months unless revoked in writing
• I may refuse to sign this authorization
• I may revoke this authorization at any time in writing
• Revocation will not apply to information already released
• Treatment is not conditioned upon signing this authorization
• Information disclosed may be subject to redisclosure by recipient

Signature: ______________________ Date: ___________________

Relationship to Patient (if not self): __________________________

For Office Use Only

Request Received: _____________ Processed By: ______________ Records Released: _____________ Method: ___________________