Authorization for Release of Medical Records - Plastic Surgery

Patient Information

Name: ______________________________ Date of Birth: ______________ Address: ____________________________ Phone: ___________________ Email: ______________________________ SSN (last 4): _____________

Release Information

I hereby authorize:

Current Provider/Practice Name: ______________________________ Address: ____________________________ Phone: _____________ Fax: ____________

To release my medical records to:

Receiving Provider/Entity Name: ______________________________ Address: ____________________________ Phone: _____________ Fax: ____________

Information to be Released

• Complete Medical Record
• Surgical Reports
• Pre/Post-operative Photographs
• Clinical Notes
• Laboratory Results
• Imaging Reports
• Billing Records
• Other: __________________________

Date Range: From __________ To __________

Purpose of Release

• Continuing Care
• Personal Records
• 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. Once information is released, the practice cannot prevent its further disclosure
4. I am entitled to a copy of this authorization
5. Treatment is not conditional upon signing this authorization

Signature: _________________________ Date: ______________

Witness: ___________________________ Date: ______________

This form complies with HIPAA Privacy Rules and Regulations