"Medical Release of Information Form"

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Medical Release of Information Form
Patient Name: ______________________________________________________ Date of Birth: ________________________
Social Security #:________________________________Previous Name: __________________________________________
Home Phone: _______________________________________ Other Phone: ________________________________________
Address, City, State, Zip_____________________________________ Phone___________________ Fax________________
I request and authorize____________________________________________________________________________________
(Name of Physician and Clinic/Practice you want to release your records)
To release the medical record of the above named patient to (the place you want your medical records to be sent):
Name of recipient: ____________________________________________________________________
Address: ____________________________________________________________________________
City & State: __________________________________________ Zip Code: ______________________
Phone: _________________________________ Fax: _______________________________________
Reason for release (required field):______________________________________________________
Health Care information relating to the following treatment condition or dates of treatment:
___________________________________________________________________
This information may contain x-ray reports, laboratory reports, EKG reports, other diagnostic reports, consults, etc.
This request and authorization applies to: (initial appropriate line)
____All Health Care information including information relating to HIV/AIDS testing, sexually transmitted diseases, psychiatric
disorders / mental health or drug and/or alcohol use. (Please circle all that apply)
____All Health Care Information excluding information relating to HIV/Aids testing, sexually transmitted diseases, psychiatric
disorders / mental health or drug and/or alcohol use. (Please circle all that apply)
Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer
protected.
Treatment or payment cannot be conditioned on my signing this authorization, except in certain circumstances such as for
participation in research programs, or authorization of the release of testing results for pre-employment purposes.
I understand I have the right to revoke this authorization by providing a written request to the above name physician or
organization. I understand that the revocation will not apply to information that has already been released in good faith. I
understand that the condition for release is not based on payment for treatment and care, enrollment or eligibility on whether I sign
the authorization.
____________________________________________________
____________________________
Signature of patient or authorized representative
Date
________________________________________________________________________________
Relationship or status if signed by anyone other than the patient (parent, legal guardian, personal representative, etc.)
Unless otherwise revoked this Authorization will expire six months from the date signed or the following designated
event:__________________________________________________________________________________________________
I understand that authorizing the disclosure of this health information is voluntary.
Revised 10.11.2012
.
Medical Release of Information Form
Patient Name: ______________________________________________________ Date of Birth: ________________________
Social Security #:________________________________Previous Name: __________________________________________
Home Phone: _______________________________________ Other Phone: ________________________________________
Address, City, State, Zip_____________________________________ Phone___________________ Fax________________
I request and authorize____________________________________________________________________________________
(Name of Physician and Clinic/Practice you want to release your records)
To release the medical record of the above named patient to (the place you want your medical records to be sent):
Name of recipient: ____________________________________________________________________
Address: ____________________________________________________________________________
City & State: __________________________________________ Zip Code: ______________________
Phone: _________________________________ Fax: _______________________________________
Reason for release (required field):______________________________________________________
Health Care information relating to the following treatment condition or dates of treatment:
___________________________________________________________________
This information may contain x-ray reports, laboratory reports, EKG reports, other diagnostic reports, consults, etc.
This request and authorization applies to: (initial appropriate line)
____All Health Care information including information relating to HIV/AIDS testing, sexually transmitted diseases, psychiatric
disorders / mental health or drug and/or alcohol use. (Please circle all that apply)
____All Health Care Information excluding information relating to HIV/Aids testing, sexually transmitted diseases, psychiatric
disorders / mental health or drug and/or alcohol use. (Please circle all that apply)
Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer
protected.
Treatment or payment cannot be conditioned on my signing this authorization, except in certain circumstances such as for
participation in research programs, or authorization of the release of testing results for pre-employment purposes.
I understand I have the right to revoke this authorization by providing a written request to the above name physician or
organization. I understand that the revocation will not apply to information that has already been released in good faith. I
understand that the condition for release is not based on payment for treatment and care, enrollment or eligibility on whether I sign
the authorization.
____________________________________________________
____________________________
Signature of patient or authorized representative
Date
________________________________________________________________________________
Relationship or status if signed by anyone other than the patient (parent, legal guardian, personal representative, etc.)
Unless otherwise revoked this Authorization will expire six months from the date signed or the following designated
event:__________________________________________________________________________________________________
I understand that authorizing the disclosure of this health information is voluntary.
Revised 10.11.2012