Medical Records and Health Care Information Release

I hereby request and authorize

to release, use or disclose Medical Records as described below:

Phone

Fax

Patient’s Full Name (Last, First, Middle Initial)

Date of Birth

Current Address

City

State

Zip

Driver’s License Number

Home Phone

Cell Phone

Work Phone

This Authorization applies to the following date(s) of Service:

Add additional dates

State Requirements for Complete Medical Records

Search, Retrieval & Other Direct Administrative Costs

Up to: $25.88

Copying Costs for Records in Paper form

Per page for pages 1-20: $0.97,
Per page for pages 21-100: $0.83,
Per page for pages over 100: $0.66

Reason for Request to Release Records

Physician/Hospital/Therapist Request

Moving from Area

Other (Please Specify Below)

Where would you like requested records sent?

Name:

Address

City

State

Zip

Phone

Fax

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 service indicated, and for the purpose written above.

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.

Name / Signature of Parent or Legal Guardian

Date

Relationship to patient

If relationship is other than parent, documentation of legal authorization(s) or Guardianship must be attached to this authorization.

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