Medical Record Release Authorization printable pdf download

Medical Record Release Authorization

Patient Name_______________________________________________________________________

Date of Birth_______________Home Phone____________________Cell/Work___________________

Address_________________________________________City/State/Zip________________________

Email Address: ______________________________________________________________________

A) I hereby authorize records FROM

B) To be released TO:

Name:

Name_______________________________________ _______________

Phone#

Address_____________________________________________________

Fax#

City/State/Zip_________________________________________________

C) For the purpose of:

_______________________

Phone#______________________FAX#___________________________

D) Records Format:

Date Range_____________________to___________________

Paper copies via postal mail

Physician’s Office Notes

Cardiology/EKG Reports

Electronic Access: (See Email Address above)

Immunizations

Lab/Path Reports

• You will receive separate instructions via email if

Operative/Procedure Reports

Radiology/XRay/MRI Reports

wish to receive your records in an electronic format

Other ________________________________________________

Fax (See Fax Number above)

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not

sign this form in order assure treatment. I understand that any disclosure of information carries with it the potential for an authorized re-

disclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health

information, I can contact the authorized individual or organization making disclosure.

I understand that the information in my medical record may include information relating to sexually transmitted disease, acquired

immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental

health services, and treatment for alcohol and drug abuse.

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so

in writing and present my written revocation to the Medical Records Department. I understand that the revocation will not apply to

information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance

company when the law provides my insurer with the right to contest a claim under my policy.

I have read the information provided on this release form and do hereby acknowledge that I am

familiar with and fully understand the terms and conditions of this authorization.

__________________________

______________________________________________________**Subject to Fees

(Date)

(Signature of Patient/Parent/Guardian or Authorized Representative)

This authorization will expire one year from the above date unless I specify an expiration date: _________________________

(Expiration date of authorization)

**PLEASE READ Fee Information: OrthoIllinois contracts with Quest Records LLC

) to copy and provide all medical

(1-800-355-9550

records requested from our office. We reserve the right to charge the fee schedule as set by the state of Illinois. However, as a

courtesy to our patients, we have instructed Quest Records, LLC to charge a discounted flat rate of $20.00 for copies of your

medical records. By signing this authorization, you are agreeing to pay Quest Records for your records. In the case of continuity

of care, we may transfer a minimal portion of your records directly to a physician as a courtesy.

For payment or status inquiries, contact:

Quest Records, LLC

1-888-355-9550

01/2016Illinois

Medical Record Release Authorization

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