"Authorization to Release Medical Records"

Authorization to Release Medical Records is a 2-page legal document that was released by the Armed Forces Retirement Home on December 1, 2020 and used nation-wide.

Form Details:

  • The latest edition currently provided by the Armed Forces Retirement Home;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more legal forms and templates provided by the issuing department.

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MRF
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C 136, Under Secretary of Personnel and
Readiness; 24 U.S.C. 401, Armed Forces Retirement Home;
DoD Directive 5124.09 Assistant Secretary of Defense for
Personnel and Readiness Force Management; DoD
Instruction 1000.28, Armed Forces Retirement Home
(AFRH); and E.O. 9397 (SSN), as amended.
PURPOSE: To determine and verify eligibility for admission
to the AFRH.
ROUTINE USE(S): In addition to those disclosures generally
permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974,
as amended, the records contained herein may specifically
be disclosed outside the DoD as a routine use pursuant to 5
U.S.C. 552a(b)(3) as follows: To the Federal Reserve for
processing the debt on the resident account; To authorized
contractors or vendors for the purpose of providing medical
services to the residents of the Armed Forces Retirement
Home; To any Federal agency which provides medical
services to residents of the Armed Forces Retirement home;
To the Inspector General of the Department of Defense or
his/her designee, for conducting inspections of AFRH
records; To a Federal agency, or an organization or person
contracting with the AFRH for information needed in the
performance of official duties related to reconciling or
reconstructing data files, compiling descriptive statistics,
and/or making analytical or financial studies to support the
MEDICAL RECORD
function for which the records were collected and
maintained; Law Enforcement Routine Use; Congressional
Inquiries Disclosure Routine Use; Disclosure of Information
to the National Archives and Records Administration Routine
RELEASE FORM
Use; Disclosure to the Merit Systems Protection Board
Routine Use; and Data Breach Remediation Purposes
Routine Use.
The applicable system of records notice is DPR 38 DoD,
Armed Forces Retirement Home electronic Resident
Information System (eRIS) and is available at: (ADD LINK
WHEN PUBLISHED).
DISCLOSURE: Voluntary; however, failure to provide the
required information may result in the delay or denial of
admission.
Cover Page
MRF 12-2020
Prior Versions No Longer Valid
MRF
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C 136, Under Secretary of Personnel and
Readiness; 24 U.S.C. 401, Armed Forces Retirement Home;
DoD Directive 5124.09 Assistant Secretary of Defense for
Personnel and Readiness Force Management; DoD
Instruction 1000.28, Armed Forces Retirement Home
(AFRH); and E.O. 9397 (SSN), as amended.
PURPOSE: To determine and verify eligibility for admission
to the AFRH.
ROUTINE USE(S): In addition to those disclosures generally
permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974,
as amended, the records contained herein may specifically
be disclosed outside the DoD as a routine use pursuant to 5
U.S.C. 552a(b)(3) as follows: To the Federal Reserve for
processing the debt on the resident account; To authorized
contractors or vendors for the purpose of providing medical
services to the residents of the Armed Forces Retirement
Home; To any Federal agency which provides medical
services to residents of the Armed Forces Retirement home;
To the Inspector General of the Department of Defense or
his/her designee, for conducting inspections of AFRH
records; To a Federal agency, or an organization or person
contracting with the AFRH for information needed in the
performance of official duties related to reconciling or
reconstructing data files, compiling descriptive statistics,
and/or making analytical or financial studies to support the
MEDICAL RECORD
function for which the records were collected and
maintained; Law Enforcement Routine Use; Congressional
Inquiries Disclosure Routine Use; Disclosure of Information
to the National Archives and Records Administration Routine
RELEASE FORM
Use; Disclosure to the Merit Systems Protection Board
Routine Use; and Data Breach Remediation Purposes
Routine Use.
The applicable system of records notice is DPR 38 DoD,
Armed Forces Retirement Home electronic Resident
Information System (eRIS) and is available at: (ADD LINK
WHEN PUBLISHED).
DISCLOSURE: Voluntary; however, failure to provide the
required information may result in the delay or denial of
admission.
Cover Page
MRF 12-2020
Prior Versions No Longer Valid
ARMED FORCES RETIREMENT HOME
Authorization to Release Medical Records
MRF
Form Completed by the Applicant
M
I
D
F
:
EDICAL
NFORMATION
ISCLOSURE
ORM
S
IGNATURE OF RELEASE IS REQUIRED FOR PROCESSING OF ANY MEDICAL FORMS
Patient’s Name:
Birthdate:
Street:
Apt.:
City:
State:
Zip:
Phone:
Cell:
Email:
(if available)
Healthcare providers: Applicants must include the examiner’s
Name, Phone,
and
FAX
numbers for the
healthcare professionals who completed the medical exam form and the functional assessment form.
Primary Care
Provider*
– Completed the Medical Exam Form
(must be a licensed MD, DO, PA, or NP)
Examiner’s Name :
Credentials*
Street:
Clinic:
City:
State:
Zip:
Phone*:
Fax*:
Email:
(If provided, email is only to be used for contact not submission of patient information)
Occupational/Physical
Therapist*
– Completed the Functional Assessment Form
(must be a licensed PT or OT)
Examiner’s Name :
Credentials*
Street:
Clinic:
City:
State:
Zip:
Phone*:
Fax*:
Email:
(If provided, email is only to be used for contact not submission of patient information)
I grant my permission to disclose information to:
Armed Forces Retirement Home
Attn: Admissions Board
3700 North Capitol Street, NW
Public Affairs Office #584
Washington, DC 20011
Tel: 202-541-7922 Fax: 202-541-7519
Specific information to be disclosed:
Patient history and office notes
Medical Records covering the last 12 months
Billing records
Insurance records
Mental Health records
Drug, Alcohol or Substance Abuse records
COVID-19 Related Information and test results
HIV/AIDS-Related Information and test results
I understand that release of this information is provided on a voluntary basis in accordance with the Privacy Act Statement Authority: 10 U.S.C 136; 24
U.S.C. 401 (full version is provided on the cover page of the application) to determine and verify eligibility for admission to the Armed Forces Retirement
Home. I understand that I may revoke this authorization at any time by giving written notice to AFRH at the aforementioned address. I also understand the
. I fully
revocation of this authorization will not affect any action taken by AFRH in reliance on this authorization prior to receipt of a written revocation
acknowledge that failure to provide any required information may result in the delay or denial of admission to the Armed Forces Retirement Home.
Patient’s
Signature*
Date*
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MRF 12-2020
Prior Versions No Longer Valid
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