Authorization for Release of Medical Records - Oncology

Patient Information

Name: _________________________ Date of Birth: _____________ SSN (last 4 digits): XXX-XX-_______ Phone: ___________________ Address: ________________________________________________

Information to be Released From

Facility/Provider Name: ____________________________________ Address: ________________________________________________ Phone: ______________________ Fax: _______________________

Information to be Released To

Facility/Provider Name: ____________________________________ Address: ________________________________________________ Phone: ______________________ Fax: _______________________

Information to be Released

• Complete Medical Record
• Lab Results
• Imaging Reports
• Pathology Reports
• Treatment Plans
• Chemotherapy Records
• Radiation Therapy Records
• Progress Notes
• Other: ______________

Date Range

From: _____________ To: _____________

Purpose of Release

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

Authorization

I understand that:

• This authorization is valid for 90 days from the date of signature
• I may revoke this authorization at any time in writing
• Information used or disclosed may be subject to redisclosure
• Treatment is not conditional upon signing this authorization
• A copy of this authorization is as valid as the original

Signature: _________________________ Date: ________________

Relationship to Patient (if not self): __________________________

For Office Use Only

Request processed by: _________________ Date: ______________ ID Verified: [ ] Yes [ ] No Method: __________________________