Medical Records Release Form printable pdf download

1005 Mar Walt Dr.

Patient ID # _____________

Fort Walton Beach, FL 32547

Internal Use Only:

Telephone #: _______________

Routine: _____________

Fax #: ____________________

Stat: _____________

Medical Records Release Form

I authorize White-Wilson Medical Center to release or obtain confidential health information about me by releasing/requesting a copy

of my medical records, or a summary or narrative of my personal health information to/from the physician/person/facility/entity below.

Patient Name: _______________________________ Date of Birth: _______________ Telephone #: __________________

Special Releases:

I consent to the release of any positive or negative test results for AIDS or HIV infection, antibodies to AIDS or infection with any

other causative agent of AIDS with the remainder of my medical records.

Initials: ________________ Date: _________________________

I consent to the release of any records related to treatment for Behavioral Health or Substance Abuse with the remainder of my records.

Initials: ________________ Date: __________________________

The information you may release, subject to my signature on this release form, is as follows:

___ Complete Records

___ History and Physical ____ Care Plan

___ Immunizations

___ Lab Reports

___ Radiology Reports

____ Pathology Reports ___ Treatment Record

___ Operative Reports

___ Hospital Reports

____ Medication Record

___ Other (please specify) ____________________________________________________________

____ 1 Year

_____ 2 Years

____ Entire Record

Release my protected health information to:

Request my protected health records from:

Name: _______________________________

Name: ______________________________

Address: _____________________________

Address: _____ _______________________

City/State/Zip Code: ___________________

City/State/Zip: ________________________

_____________________________________

____ Mail

____ Pick Up

____ Fax

____ Other (Specify): _______________

Phone #: ___________ Fax #: (Doctor’s Only) ____________ Phone #: _______________Fax #: (Doctor’s Only) ____________

I understand that:

1. I may refuse to sign this authorization as it is strictly voluntary, however, records cannot be released without authorization.

2. My treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization.

3. I may revoke this authorization at any time in writing. Prior releases of information remain covered under the authorization

in place at the time they were released.

4. If records are released to an individual other than a health care provider or health plan that information may no longer be

protected by federal privacy regulations.

5. I understand that there may be a fee for records released to an individual other than a health care provider.

6. I may request a copy of this form after it is signed and dated.

Patient’s Signature: _____________________________________________ Date: ___________

(Required for all patients 18 years and older)

Signature of Parent/Legal Guardian: _______________________________ Date: ___________

(Required for all patients under 18 years of age unless otherwise allowed by law. If legal guardian is signing, appropriate documen-

tation must accompany this form)

Records will be provided to another health care provider at no cost. There is a copy fee for release of medical records for the patient's personal use.

Prepayment is required before records can be released.

Medical Records Release Form

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