Generic Medical Records Release Form printable pdf download

Medical Records Release Form

Authorization for Use/Disclosure of Information: I voluntarily consent to an authorize my

health care provider ________________________________________ (insert name)

to use or disclose my health information during the term of this Authorization to the

recipient(s) that I have identified below.

Recipient: I authorize my health care information to be released to the following

recipient(s):

Name:______Island Health & Wellness Center, Inc____________________

Address:__5000 Estate Enighed PMB 311 St. John, VI 00830____________

Phone: 340-714-4270

Fax: 888-979-9488

Purpose: I authorize the release of my health information for the following specific purpose:

_______________________________________________________________________.

(Note: “at the request of the patient” is sufficient if the patient is initiating this Authorization)

Information to be disclosed: I authorize the release of the following health information:

(check the applicable box below)

All of my health information that the provider has in his or her possession, including

information relating to any medical history, mental or physical condition and any

treatment received by me.

Only the following records or types of health information:

__________________________________________________________________.

Term: I understand that this Authorization will remain in effect:

From the date of this Authorization until the _____ day of ________, 20___.

Until the Provider fulfills this request.

Until the following event occurs:________________________________________

Permanently

Redisclosure: I understand that my health care provider cannot guarantee that the recipient

will not redisclose my health information to a third party. The third party may not be

required to abide by this Authorization or applicable federal and state law governing the use

NOTE: This Authorization does not extend to HIV test results, outpatient psychotherapy notes, drug or alcohol

treatment records that are protected by federal law, or mental health records that are protected by the Lanterman-Petris-

Short Act.

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Generic Medical Records Release Form