Medical Release Policy

EFFECTIVE APRIL 14, 2003, THE FOLLOWING POLICY WILL BE ADHERED TO FOR ALL RELEASES OF MEDICAL INFORMATION

No Medical Information will be released without written consent from either Parent/Legal Guardian for minor children under 18.
Children over 18 MUST SIGN FOR THEIR OWN RECORDS.
Any HIPAA protected sensitive Information may also require the chi ld's signature if the child is over the age of 12.

Authorization for Release of Medical Information

Patient's Name:

Date of Birth:

Address:

City/State/Zip Code:

SS#:

Patient's phone #:

Date of Request:

Date Needed:

Reason for request:

I authorize stated person below to release information to:

Name of Authorized Person:

Name of Provider or Facility:

Address:

City, State, Zip Code:

Phone #/Fax # (include area code):

I authorize stated person below to obtain information from:

Name of Authorized Person:

Name of Provider or Facility:

Address:

City, State, Zip Code:

Phone #/Fax # (include area code):

Other.

If other, please describe:

Entire copy of the record checked above.

AUTHORIZATION VALID FOR : (Check one.)

This request only.

One year from the date of this authorization OR stated date. This authorization applies to the records of the treatment received on or prior to the date of this authorization.

Insert Date:

This request and for medical records of any future treatment of the type described above until stated date.

Insert Date:

I understand that:

My right to healthcare treatment is not conditioned on this authorization.
I may cancel this authorization at any lime by submitting a written request to the address provided at the top of this form, except where a disclosure has already been made in reliance on my prior authorization.
If the person or facility receiving this information is not a health care or medical insurance provider covered by privacy regulations, the information slated above could be redisclosed.
Release of HIV-related information, mental health related care, or substance abuse diagnosis and treatment information requires additional authorization.
There may be a charge for the requested records.

NOTE: Medical records are faxed in cases of medical necessity only.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient or Representative:

Date:

Relationship to Patient: (if requester is not the patient)

Your information will be encrypted.