REQUEST FOR MEDICAL RECORDS

Patient Name:

Birth Date:

Full Address:

Phone #:

NAME AND ADDRESS OF DOCTOR/FACILITY WHERE PATIENT’S MEDICAL RECORDS ARE LOCATED

Name: LEON W. LEWIS MD, P.C.

Address: 420 Lowell Drive, Suite 401 Huntsville, AL 35801

Fax: 256-489-8849

Other:

PROVIDE A COPY OF MY MEDICAL RECORDS TO ME:

SEND SPECIFIED AND AUTHORIZED MEDICAL RECORDS TO:

Name:

Fax #:

Address:

INFORMATION TO BE RELEASED:

If you fail to specify, a 1-year abstract will be provided

Please release a 1-year abstract of my records (includes most recent notes, labs, procedures & testing)

Please release ALL of my records.

History & Physical

Billing Record

Operative Report

Diagnostic Test/Results (lab and other test results)

Pathology Report

Progress Note

Radiology Images (CD or DVD)

Mental Health Records

Other:

Operative Report:

Other:

Special Authorization: Your initials are required to release the following information

Mental Health Records (excluding psychotherapy notes)

Drug, Alcohol, or Substance Abuse Records

Genetic Information (including Genetic Test Results)

HIV/AIDS Test Results/Treatment

DELIVERY METHOD:

Mail

Pickup

Fax

I expect the holder of my medical records to mail or make ready for pickup my specified medical records as soon as reasonably possible, not to exceed 30 days, unless my records are off-site which allows for an additional 30 days.

FOR THE PURPOSE OF:

(check all that apply)

Personal use

Treatment

Form Completion

Legal

Insurance

Other

If Other, Please specify

EFFECTIVE TIME PERIOD. This authorization is valid until:

Date

If I do not specify expiration this authorization will expire in 90 days.

RIGHT TO REVOKE: I understand that I can withdraw my permission at any time by giving written notice stating my intent to revoke this authorization to the person or organization named under

WHO CAN RECEIVE AND USE THE HEALTH INFORMATION. I understand that prior actions taken in reliance on this authorization by entities that had permission to access my health information will not be affected.

SIGNATURE AUTHORIZATION: I have read this form and agree to the uses and disclosures of the information as described. I understand that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that is otherwise permitted by law without my specific authorization or permission. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws

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

Signature of Patient Only:

Date

If you are NOT the patient but are signing on behalf of the patient, please complete below and attach proof of your authority to act on behalf of the patient (other than parent).

am, the

Representative's Signature:

Date

Internal Use:

Type of Identification Provided

Driver's License

Passport

Military ID:

Other ID:

Your information will be encrypted.