Authorization For The Release Of Medical Records
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1Acupuncture Clinic for Pain Relief & Sports Medicine
Authorization for the Release of Medical Records
This authorization must be written, dated and signed by the patient or by a person authorized by law to give authorization. It is valid until
.
revoked in writing. Records are requested for continuity of care. This clinic does not offer reimbursement for records received
Patient: __________________________________
Social Security #: ______-______-_______
DOB:_____/_____/_____
Please obtain information from the following:
Please send my medical information to:
_________________________________________
Name of Physician
__________________________________________@
Name of Person to Receive Information
_________________________________________
Name of Clinic/Hospital
Robert Fueston
3166 Custer Dr., Suite 201
_________________________________________
Lexington, KY 40517
Phone: 859-273-1011 / Fax: 859-273-1041
Street Address
Website:
_________________________________________
City, State, Zip Code
By checking the spaces below, I authorize the above physician/clinic/hospital to release written records pertaining to the following
information going back one year. I also authorize the above physician/clinic/hospital to provide the following information via telephone
consultation:
____ Medical records needed for
____ Diagnostic imaging reports
____ Pathology reports
continuity of care
____ Laboratory reports
____ Other: ___________________________________________________________________________________________________
________________________
_________________________________________________________________________________
Date
Patient Signature
__________________________________________________________________________________
Signature of Parent/Guardian if Applicable
I understand that certain information in these records cannot be released without specific authorization because of federal or state laws. By
signing the spaces below, I specifically authorize the release of the following confidential information for us by above said
physician/clinic/hospital. I also authorize the above physician/clinic/hospital to provide the following information via telephone consultation:
________________________________________________ HIV/AIDS test results and related information, including high risk behavior
Patient Signature
documentation. This information may not be further disclosed without
The specific written authorization of the tested individual
________________________________________________ Drug/Alcohol diagnosis, treatment, or referral information. Federal
Patient Signature
Regulation, 42 CFR Part 2, requires a description of how much and what kind
Of information is to be disclosed. Please provide a description of this
information:
____________________________________________________
_______________________________________________________________
________________________________________________ Mental Health treatment information
Patient Signature
Office use only:
Date sent: ______________ Initials: _______________
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