Authorization To Release Medical Information Form printable pdf download

Authorization for Release of Medical Information

MRN___________________________

I hereby authorize the release of information from the medical record of:

Patient Name:________________________________________________________

Date of Birth:____________________________

Social Security #:________________________________________________(optional)

Daytime Phone #:________________________

Information Released

TO: ___________________________________________________

FROM: ________________________________________________________

______________________________________________________

_______________________________________________________________

______________________________________________________

_______________________________________________________________

Please release the following:

Problem List

X-ray reports

Progress Notes

X-ray films

History/Physical Exam

EKG reports

Lab Reports

Other diagnostic reports (specify) ________________________________________________

Immunizations

Other (specify) _________________________________________________________________

Including information (if applicable) pertaining to:

Mental Health

Drug/Alcohol

HIV/AIDS

Communicable Treatment

Purpose or Need for Disclosure:

Continued Patient Care

Personal Use

Attorney/Legal

Insurance Claim/Application

Disability Determination

Other (specify) ________________________________________________________________

I understand that the information released is for the specific purpose stated above. Any other use of this information without the written consent of the

patient is prohibited. I further understand that I may revoke this consent (in writing) at any time except to the extent that action has been taken in

reliance on it. This consent will expire 90 days after the date of my signature unless otherwise specified.

_______________________________________________________________

_____________________________________________

Signature of Patient or Legal Representative

Date

________________________________________________________________

_____________________________________________

Relationship to Patient

Witness

COMPLETE ONLY IF INFORMATION IS TO BE RELEASED DIRECTLY TO THE PATIENT:

I understand that my medical record may contain reports, test results, and notes that only a physician can interpret. I understand and have been advised

that I should contact my physician regarding the entries made in my medical record my misunderstanding of the information contained in these entries.

I will not hold 1960 Family Practice liable for any misinterpretation of the information in my medical record as a result of not consulting my physician

for the correct interpretation.

_________________________________________________________________

_____________________________________________

Signature of Patient or Legal Representative

Date

_________________________________________________________________

_____________________________________________

Relationship to Patient

Witness

Date request completed _________________________

# of pages __________________

Reviewed only ________________________