Medical Records Request 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, Dr. Stacy Hausmann and North Woodmere Medical Care, PLLC to release health information on the patient named below:

Patient Name

Date of Birth

Other Name i.e.; (maiden)

Telephone

Address

City

State

Zip

I hereby authorized the release of:

ALL my health information related to the healthcare services provided to me by Stacy Hausmann, MD, MS 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 on the date of treatment and any healthcare information related to services received prior to the date of service.

Include Previous Provider Records

My health information relating to the following treatment or condition:

Please list Treatment/Condition:

My health information for the date(s):

Please list date(s):

Other:

If Other, please specify:

Reason for Release (must be noted):

Patient Name

If Minor Patient, List Parent/Guardian's Name

Send Medical Records To:

Address

City

State

Zip

Phone

Consent to Email: I give Dr. Stacy Hausmann and North Woodmere Medical Care, PLLC permission to email protected health information (COVID-19 Test Results) for myself or my child via a secure encrypted email to the email that I provide. I understand that the email I provide may not be encrypted.

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 testing results, sexually transmitted disease; eating disorder, 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 that your electronic signature is the legal equivalent of your manual signature on this application.

Signature (Or Parent/Legal Guardian if Minor)

Date

Signature of Responsible Party

Date

Your information will be encrypted.