Medical Records Release Consent Form

Patient Authorization for Use or Disclosure of Protected Health Information

As required by the Health and Accountability Act of 1996 (HIPAA), a practice may not use or disclose your identifiable health information without your authorization except as provided in our Notice of Privacy Practices. Your completion of this form means that you give permission for the uses and disclosure described below. Please review and complete this form carefully. It may be invalid if not fully completed. You may wish to ask the person or entity you want to receive your information to complete those sections detailing the information to be released, and the purposes for the disclosure.

I hereby authorize

to release health information on the patient named below:

Patient Date of Birth

Other Name i.e.; (Maiden)

Phone Number

Address

City

State

Zip

I hereby authorize the release of:

ALL my health information including, but not limited to, history, physical, diagnosis, treatment plan, laboratory, diagnostic and/or radiology studies and any pertinent information to your care and treatment of me.

Include Previous Provider Records

My health information relating to the following treatment or condition:

Please Specify Treatment/Condition:

My health information for the date(s):

Please List Date(s):

Other

If Other, please specify:

Reason For Release (must be noted):

Date of Request

Patient Name

If Patient is a Minor, List name of Parent/Guardian

Release Medical Records To:
NORTH WOODMERE MEDICAL CARE, PLLC
636 Michelle Place
Valley Stream, NY 11581
Office Number: 516-791-9010
Fax Number: 516-758-1035

RESTRICTIONS: I understand that the recipient of this information may not use or disclose this information except for the expressed purposes identified above, unless another authorization is obtained from me, or such use or disclosure is specifically required or permitted by law.

I understand that my medical record may include information relating to COVID-19 test results, sexually transmitted disease; acquired immunodeficiency syndrome (AIDS); human immunodeficiency virus (HIV); behavioral/mental health services; and/or treatment for alcohol and/or drug abuse.

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

Signature of Patient/Guardian/Parent/Patient Representative

Date

Your information will be encrypted.