Medical request form

Requested by:

Name of patient

Address

City, State, Zip

Phone#

SSN#

DOB

Records to come from:

Rosemark or requesting provider

Phone#

Address

City, State, Zip

Fax# (Required)

Date records requested

Records to be released to:

check one:

Mail Fax Pickup in person Secure email

if other than the patient please specify who will pickup:

please bring ID

Email address to send records to:

Name/Office to send records to:

Fax# (Required)

Address

City, State, Zip

Reason for request:

Changing practices Dr. Consultation For own use

Requested records

Entire chart Partial chart Labs

If partial- what date range

If labs- what labs

This authorization ends on:

Signature of patient or representative

Your typed full name will act as your digital signature

Today's date

As a patient of Rosemark Women Care Specialists, you are entitled under federal law to access your Personal Health Information (PHI). Your records are protected and cannot be disclosed without your written permission. If you have any questions or concerns regarding the handling of your PHI, or if you wish to view your PHI, contact our Privacy Officer at (208) 557-2924.