Medical Record Release Form

Patient Name:

DOB:

SSN:

This request expires on

If left blank, expires 1 year from signing or until revoked in writing.

I authorize you (TRAAC) to release confidential health information about me, by releasing a copy of my medical records, or a summary or narrative of my protected health information to the person(s) or entity listed below:

Doctors Name:

City:

State:

Zip Code:

Fax:

Phone:

Email:

Dates of information to be disclosed:

From:

To:

If left blank only information from the past two years will be disclosed.

Information to be disclosed:

All medical records related to: (Specify condition, treatment, etc.) All diagnostic testing related to: (Specify condition, treatment, etc.) All billing records related to: (Specify condition, treatment, etc.)

Please specify:

I do not want the following information disclosed (as defined by applicable state and federal laws):

Alcohol/Drug Abuse HIV test Results Mental Health/Developmental Disabilities

I understand that there may be a fee associated with the release of my medical records and agree to payment.

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.

Patient/Guardian printed name

Patient/Guardian signature

Date

Your information will be encrypted.