Medical Records Release/request Form - Enclave Family Healthcare printable pdf download

Medical Records Release/request Form - Enclave Family Healthcare

Medical Records Release/Request Form

(Check One)

Release

_____Releasing information from us to you or your provider

Request

_____Requesting information from another provider to us

Date: _______________

Name: ______________________

Date of Birth: ________________

Address: ______________________________________

Phone: ________________

Social Security #: ____________________

I authorize the Enclave Family Healthcare, PLC to release/request (circle one) the following:

Information Requested:

Purpose of Request: _______________________________

Duration of Authorization: _______________________

To/From (circle one) Name: ________________________________

Address: ________________________________________________

Phone and Fax: ___________________________________________

(It is important that you give as much contact information as you can, especially the provider’s name and

phone.)

• I understand that this authorization shall be valid through ________________(date), but

that I may revoke it in writing at any time; any such revocation shall have no effect on

disclosures made previously.

• I understand that I have the right to inspect and copy the information to be released.

• I understand that if I refuse to consent to disclosure of information, the agency may be unable

to serve me and/or may be unable to provide the most appropriate care for me.

• I understand that the release of information may not be re-released to any other person or

organization without my written consent.

Signature ___________________________ Date ___________________

Witnessed by ____________________________ Date ___________________

Medical Records Release/request Form - Enclave Family Healthcare