Medical Release Of Information Form printable pdf download

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