Authorization for Release of Medical Records - Neurosurgery

Patient Information

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

Records To Be Released From

Practice Name: __________________ Physician: ______________________ Address: ________________________ Phone: _________________________ Fax: ____________________

Records To Be Released To

Practice/Person: ________________ Address: ________________________ Phone: _________________________ Fax: ____________________

Information to be Released

(Check all that apply)

• Complete Medical Record
• Neurological Examination Results
• Imaging Studies (MRI, CT, X-rays)
• Operative Reports
• Laboratory Results
• Progress Notes
• Other: ___________________

Date Range

From: _____________ To: _____________

Purpose of Release

(Check one)

• Continuing Care
• Personal Use
• Insurance
• Legal
• 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. Information disclosed may be subject to redisclosure by the recipient
4. I have the right to receive a copy of 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