Release of Records to RCFM

Patient's Name

Date of Birth

Previous Name

Phone #

I request and authorize

Name/Facility

Address

City

State

Zip

Phone

Fax

To Release Information to

Rocky Creek Family Medicine (RCFM)
3281 Rocky Creek Drive, Ste 500
Missouri City, TX 77459
Ph: 281-206-0068 Fax: 281-499-5045

Purpose of Release

Patient is moving

Transfer of Care to New Provider/Practice (Last 5 years)

Personal

Receiving Secondary Care

Insurance Purposes

Other, Please Specify

New Address

If last 5 years, Please specify

If Other, Please specify

Information to be released

Last one year of medical records

Last three years of medical records

Last five years of medical records

Immunization Records Only

Radiology Reports

Lab Reports Only

Payment/Claim Records

Other

Other, Please specify

Sensitive information to be released

Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes simplex, human papilloma virus, wart, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereum, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea.

I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s)/facility listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.

Yes No

I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s)/facility listed above.

Yes No

This authorization may be revoked at any time except to the extent any person has taken action in reliance upon this authorization. Further details on the revocation of this authorization are included in the facility’s notice of privacy practices. The revocation must be made in writing to the facility releasing the information. The revocation may be the basis for denial of health benefits or other insurance coverage or benefit. Information released pursuant to this authorization may be subject to re-release by the recipient and may no longer be protected by federal or state law. A copy of this authorization is available upon request.

RCFM will not condition treatment on the signing of this authorization. I may refuse to sign. If I refuse to sign, it may result in an improper diagnosis, treatment, denial of coverage, denial of claim benefits, denial of other insurance, or other adverse consequences.

This authorization expires 12 months from the date of my signature below. During the 12-month period, RCFM may make subsequent disclosures to the recipient named above.

I, the undersigned, hereby authorize the release of the protected health information described above subject to the restrictions described 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.

Patient / Guardian Signature

Date

Guardian Name, if applicable

Relationship

DEADLINE FOR RELEASE OF RECORDS: THE REQUESTED COPIES OF MEDICAL AND/OR BILLING RECORDS OR A SUMMARY OR NARRATIVE OF THE RECORDS SHALL BE FURNISHED BY THE PHYSICIAN WITHIN 15 BUSINESS DAYS AFTER THE DATE OF RECEIPT OF THE REQUEST AND REASONABLE FEES FOR FURNISHING THE INFORMATION.

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