Medical Records Release Form

AUTHORIZATION for the Release of Health Information

Patient First Name:

Middle Initial:

Last Name:

Date of Birth:

Phone Number:

Address: Street

City:

State:

Zip:

Email address

I hereby authorize Family Footcare to RELEASE my medical information to Health Provider or Entity

I hereby authorize Family Footcare to RECEIVE my medical information from Health Provider or Entity

Sending provider to send medical information to:

Family Footcare Group, LLP
427 Broadway Suite 2
Monticello, NY 12801
Tel. (845) 692-3668
Fax (845) 794-0228

Name:

Attention of:

Street Address:

City:

State:

Zip:

Telephone #:

Fax # (required for Health Provider)

Information to Release (please select all that apply)

Medical Records

from

Entire Medical Record, including patient history, office notes, test results, radiology reports and consults

Billing records

Please specify:

Other

Please specify:

Include by Initialing:

Alcohol / Drug Treatment

HIV Related Info and Test Results

Mental Health Information

Medical Records Released by Family Footcare Group / Copying Fee: $0.75 per page

X-Ray

Add date

X-Ray CD Cost $10.00 / disk

Authorization to Discuss Health Information

By initialing here

Initials

I authorize

to discuss my health information with:

Name:

Relationship:

Reason for Requested Use or Disclosure

Personal Use

Legal

Second Opinion

Change in Health Care Provider

Other

If Other, please specify:

This authorization expires in six (6) months from the date signed or earlier

Date:

TO BE READ AND SIGNED BY PATIENT:

I understand the following:

I may revoke this authorization at any time by providing written notice to the practice
I may not be able to revoke this authorization if the practice has already taken action utilizing this authorization, or if the authorization was obtained as a condition of obtaining insurance coverage.
The practice will not condition treatment or payment based on my signing this authorization.
I am signing this authorization freely and under no pressure from any individual to do so
The information disclosed in this authorization may be subject to re-disclosure by the practice and no longer protected by federal law
I acknowledge that I have had an opportunity to review this authorization and understand the intent and use
This authorization my include disclosure of information relating to ALCOHOL and DRUG ABUSE and CONFIDENTIAL HIV RELATED INFORMATION only if I place my initials on the appropriate box above.
If I am authorizing the release of HIV related, alcohol or drug treatment information, the recipient is prohibited from re-disclosing such information without my authorization unless permitted to do so under federal and state law. I understand that I have the right to request a list of people who may receive or use my HIV related information without authorization. If I experience discrimination because of disclosure of HIV related information, I may contact the New York State Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights.

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 Legal Representative: