Medical Records Release Blank - Crystal Lake Clinic printable pdf download

Medical Records Release Blank - Crystal Lake Clinic

AUTHORIZATION FOR RELEASE OF INFORMATION

Patient/Client Name

Date of Birth

Address (street, city, state, zip)

Phone Number (please include an alternate phone number too)

I Hereby Authorize:

To Release To:

Provider:

Phone:

Fax:

I authorize its Director or designee, or Medical Record Department, to release information contained in my

patient records to the individuals or organizations listed above, only under the conditions listed below:

These records to include, if any, alcohol and drug abuse records protected under the regulations in 42 Code of

Federal Regulations, Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA); social

services records; and psychological services records, including communications made by me to a social worker or

psychologist, and all information defined by statute and Michigan Department of Public Health Rules (Public Act

174, 1989) governing Human Immunodeficiency Virus (HIV), HIV Test, Acquired Immunodeficiency Syndrome

(AIDS), and IADS-related complex (ARC).

Specific Information to Be Disclosed

Progress Notes

History and Physical

Lab Reports

EKG

X-ray Reports

Pathology Report

Operative Report

Complete chart

Records relating to a specific problem:

Purpose and Need for Such Disclosure – A sufficient purpose may be “Personal Use”

Continuation of Care

Insurance/Worker’s Comp

Personal Use

Legal/Attorney

Disability

Other:

Rev 10/19/15

Medical Records Release Blank - Crystal Lake Clinic