Medical Release Form

Patient Name

Date of Birth

Phone #

Patient Address

City

State

Zip

For Record Release or Copies:

By signing this authorization, I authorize the party listed below to use and/or disclose certain
protected health information (PHI) about me / my child.

This authorization permits:

Provider’s Name

Phone #

Street Address

City

State

Zip

to use or disclose to:

New Provider, Specialist, or Person Receiving Copy

Phone #

Street Address

City

State

Zip

Information to be Released/Copied

All pertinent medical records including immunizations and lab tests

Encounter Notes

Lab Info

Other please specify

Information to be Excluded/Not Released

Mental Health Records

Drug/ Alcohol Treatment

HIV Testing

Sexual Assault/Victimization Records

Other

If other, please specify

Reason for Record Release or Copy

Personal Copy <see below / charges apply

Over age 21

Insurance Change

Moving/ Changing Providers

Referral to Specialist

Unhappy with Practice

Please state why

Other

If other, please specify

For Patient or Guardian Inspection/Copy Requests:

I understand and agree that I am financially responsible for the following fees associated with my request: copying charges, including, the cost of supplies and labor, and postage related to the production of my information. I understand that the charge for this service is: $.50 per page for the first 25 pages, then $.30 for each page thereafter.

Signature of Patient or Legal Guardian

Date

Print Name of Patient or Legal Guardian

FOR INTERNAL PURPOSES ONLY:

Name and Title of Person Releasing Records

Method of Transfer

Mailed on (date)

Certified? (certification #)

Faxed to (number)

on (date)

Emailed to

Name

E-mail

on (date)

Your information will be encrypted.