Authorization for Release of Medical Records - Vascular Surgery

Patient Information

Name: _________________________ Date of Birth: _________________ Address: _______________________ Phone: _______________________

Records To Be Released From

Facility/Provider Name: ________________________________________ Address: ___________________________________________________ Phone: _________________________ Fax: ________________________

Records To Be Released To

Facility/Provider Name: ________________________________________ Address: ___________________________________________________ Phone: _________________________ Fax: ________________________

Information to be Released

(Check all that apply)

• Complete Medical Record
• Vascular Studies/Imaging Reports
• Laboratory Results
• Operative Reports
• Progress Notes
• Consultation Reports
• Other: ________________________________________________

Date Range

From: _____________ To: _____________

Purpose of Release

(Check one)

• Continuing Medical Care
• Insurance
• Legal
• Personal Use
• Other: ________________________________________________

Authorization

I understand that:

1. This authorization expires one year from the date signed unless otherwise specified
2. I may revoke this authorization at any time by notifying the providing organization in writing
3. Information used or disclosed pursuant to this authorization 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

Date Received: _________________ Date Processed: ________________ Processed By: __________________ Records Sent: _________________