Medical Records Request Form

Please correct the errors described below.

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:

I hereby authorized the release of:

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.

Your information will be encrypted.