Medical Records Release printable pdf download

Medical Records Release

Please Print Clearly & Fill-in All Sections Completely

Patient’s Name:

Date of Birth:

______

Address (street, city, state & zip code):

Last Four of SSN:

I authorize Orthopedic Associates of SW Ohio and/or the Hand Center of Southwestern Ohio, custodian of my medical

records, to disclose/release the following Protected Health Information: (please check all that apply)

 All records

 Operative Reports

 Progress Notes

 X-ray/radiology records

 Billing records

 Other

OR: Release ONLY the specific dates of service as listed:_______________________________________

*Note: If these records contain any information from previous providers or information about HIV/AIDS

status, cancer diagnosis, drug/alcohol abuse, or sexually transmitted disease, you are hereby authorizing

the disclosure of this information.

Please send the records indicated above to:

Name:

Address:

Phone:

Fax:

The information being requested is for (please mark all that apply):

 Second Opinion

 Legal (Specify)

 Specialist Care

 Temporary Transfer of Care (Indicate Dates)

 Permanent Transfer of Care

 Other (Specify)

This authorization is valid for one-hundred-eight (180) days from the date it is signed. I understand that after the custodian of records for Orthopedic

Associates of SW Ohio and/or the Hand Center of Southwestern Ohio discloses my health information, it may no longer be protected by federal privacy

laws. I certify that this request has been made freely, voluntarily and without coercion and that the information given above is accurate and complete

to the best of my knowledge and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment; receive

payment; or eligibility for benefits unless allowed by law. I may revoke this authorization in writing, at anytime. I understand that a revocation of this

authorization has no effect on records that have already been disclosed in response to authorizations received prior to the written notice of revocation.

Written revocation is effective upon receipt by the Medical Records Department of Orthopedic Associates of SW Ohio. By signing below I represent and

warrant that I have authority to sign this document and authorize the use or disclosure of protected health information and that there are no claims or

orders pending or in effect that would prohibit, limit or otherwise restrict my ability to authorize the use or disclosure of this protected health

information.

____________

Signature of patient (or patient’s representative)

Date

____________

Printed name of patient or patient’s representative

Representative’s authority to sign for patient

(i.e. parent, guardian, power of attorney for healthcare)

All records will be mailed by Healthport to address listed above. Please allow 30 days for completion.

Signature OASWO Witness: ________________________________

Date: __________________________________