Medical Record Release Of Information Authorization (Page 2 of 2) in pdf

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Medical Record Release of Information Authorization

Be sure to complete all fields so that you can be contacted with any issues that may arise. Failure to

provide any of these fields will result in delays of the delivery of the medical information.

Patient Name:_________________________________ Date of Birth: _____ / _____ / __________ SSN #: (last 4)- _______________

AKA or Maiden Names: ________________________________________________________________________________________

Patient Address: ______________________________________________________________________________________________

City: ______________________________________________State: _____ Zip Code: _____________ Phone: (

) _____ - ________

Email: ________________________ @ _____________________________ . ________ Fax: (

) _____ - ________

Where you would like info sent to

Doctor you would like information from

Please indicate all fields even if you would like the records faxed. Larger files

cannot be faxed and RRS will need a complete mailing address

☐ Self

Doctor Or Facility Name:_________________________________

Address: _____________________________________________

City: ________________________________________________

State: _____ Zip Code: ___________ Fax: (

) _____ - ________

State: _____ Zip Code: ___________ Fax: (

) _____ - ________

In order to receive the fastest services please specify the information that is being requested. Larger files will take longer to process and

deliver. Reducing requests to the minimum necessary allows RRS to provide the quickest turnaround times.

Dates of Service: - From: _____\_____ __________ - To: _____\_____ __________

Incident or Injury Date: _____\_____ __________

Specific Information: ___________________________________________________________________________________

_______________________

Purpose of Disclosure - Please select one:

☐ Referral to Specialist

☐ Insurance

☐ Workman’s Comp

☐ Legal Investigation

☐

☐ Personal

Disability Determination/ Claim

☐ Transfer of Care

☐ 2

Opinion

☐ Other: _______________

n d

You MUST agree or disagree to each of the following. Please be advised that disagreeing to any of the following may result in portions of your medical file

being withheld from the response

Unless otherwise revoked, this authorization will expire six months from the date from which it was originally signed or on the following date ____/_____/_________

My evaluation, diagnosis, and/or treatment relating to the conditions listed below may be released to the requestor identified above for the following type of records

unless otherwise indicated.

Agree ______ Disagree _____ - AIDS (Acquired Immunodeficiency Syndrome) or HIV (Human Immunodeficiency Virus) Infection

Agree ______ Disagree _____ - Psychiatric care and/or psychological assessment

Agree ______ Disagree _____ - Treatment for alcohol and/or drug abuse.

Agree ______ Disagree _____ - Mental Health Treatment

Failure to complete this section will automatically imply a declination of the above

I understand that I have the right to revoke this authorization at any time. I understand that my revocation must be in writing and addressed to the privacy officer of the above named facility

authorized to make this disclosure. I understand that the revocation does not apply to information already released in response to this authorization.

I understand that any disclosure of information may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law. I understand that I need not sign this

authorization to assure continued treatment. I understand that I may inspect and/or copy the information to be disclosed. I understand that authorizing this disclosure is voluntary. I understand that if

I have questions about disclosure of my health information, I may contact the privacy officer at the facility listed above that is authorized to disclose this information and request a copy of this

authorization.

I understand that there may be a fee for this service.

Requests cannot be processed without proper authorization. Minors must have a parent signature. Individuals requesting records on

deceased or adult patients must provide the required Power of Attorney or other supporting legal documents.

_______________________________________________________________________________________ Date: __________________

Signature of Patient or Authorized Representative