MEDICAL RECORDS RELEASE AUTHORIZATION

All information contained in this questionnaire is strictly confidential and will become part of your medical record.
Medical records cannot be released until this form is completed, signed, and returned.

1. Patient information

Name:

Date of Birth:

S.S.N.

Address:

Telephone

Email:

2. Type of release authorization

I authorize VI Medical & Surgical Associates, LLC to release medical records information to:

I authorize VI Medical & Surgical Associates, LLC to obtain medical information on me from:

Practice/Hospital Name:

Address:

Phone:

Fax:

3. Purpose for request

At the request of the patient

Transfer of records to new physician

Other (please specify):

4. Information needed

The entire medical record, excluding mental health treatment, drug abuse treatment, and HIV/AIDS records

History & Physical

From date:

Laboratory results

From date:

Radiology Results

From date:

Other (please specify):

5. Authorization:

I understand that I have the right to inspect and copy the information I have authorized to be disclosed. In the event I refuse to authorize the release of the above described information, I understand that it will not be disclosed, except as provide by law. I understand that VI Medical & Surgical Associates, LLC may not condition treatment on whether I sign this authorization. I understand that this authorization will expire in 12 months unless otherwise stated. I understand that I may revoke this authorization at any time by giving written notice.

Patient’s or Legal Representative’s Signature:

Date:

Your information will be encrypted.