Medical Records Release Form
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11614 Peachtree Parkway • Suite #200 • Cumming, GA 30041
Phone: (678) 455-2295
Fax: (678) 455-2279
Medical Records Release Form
Please provide the following information that is needed to assist the provider in locating the patient’s records:
Patient Name _________________________________ Date of Birth __________ SSN ________________
Address ________________________________________________________Maiden name___________
Phone: Home ______________________ Work _______________________ Cell ____________________
REQUEST AUTHORIZATION
To provide copies of my records to Commonwealth Primary Care, LLC from:
(initial)
Name (receiving person/party):
Fax #:
Address:
Phone #: (required to verify Fax #)
To provide copies of my records checked below to:
Name (receiving person/party):
Fax #:
Address:
(initial)
Phone #: (required to verify Fax #)
To permit review of my records checked below by (person’s name):
(initial)
This authorization applies to records from the following date or dates of service: ______________________________________
PURPOSE OF DISCLOSURE
□ At the request of the individual (patient)
□ Other:
DESCRIPTION OF INFORMATION TO BE RELEASED
The information used/disclosed pursuant to this authorization will not include psychotherapy notes (meaning detailed notes kept by your
psychiatrist or psychotherapist), but may include other detailed mental health information, HIV/AIDS information and/or information regarding
alcohol or substance abuse.
□
□
Entire Medical record
Emergency Room Records
□
Financial Reports
□
History and Physical Reports
□
□
Radiology Reports
Discharge Summary Reports
□
□
Laboratory/Pathology Reports
Medication Records
□
□
EKG/ECG Reports
Other (Please Specify)
I understand that the information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient of the
information and may then no longer be protected by the federal privacy regulations. I understand that unless otherwise limited by state or federal
regulations, I may revoke this Authorization at any time by presenting my revocation in writing except to the extent that the entity identified above
has taken action in reliance on this Authorization. I further understand that this Authorization is specific to the information checked above, for the
date(s) of services indicated, and for the purpose written above. Commonwealth Primary Care, LLC providers shall not condition treatment on
the receipt of this Authorization, except when such conditioning is permitted for research-related treatment or in instances where the sole
purpose of creating the health information is for disclosure to a third party (for example, fitness-for-duty exams).
I further understand that this Authorization is valid for a period of 90 days from today’s date and will expire at that time unless another date
is written here:
___________________________________
________________________________________
____________________________
Today’s date Time
Patient or Legal Representative signature
Patient Name (PRINT)
As Legal Representative, my relationship to the patient is: _______________________________
The patient is unable to sign because:
NOTE: There may be fees for provision of any or all requested information. I understand that I will be responsible to pay
Commonwealth Primary Care, LLC $0.50/page up to 50 pages and $0.25/ page thereafter, to photocopy and release my medical
records. Under most circumstances, the law permits up to 30 days for record requests to be processed, however records for
treatment purposes can be immediately faxed to the patient’s healthcare provider when requested. Parties receiving records related to
this consent may not redisclose without a separate written consent except from a provider where permitted by law.
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