Medical Records Request Form printable pdf download

MEDICAL RECORDS REQUEST FORM

Please complete this form if you want to request to have your records sent to

OB-GYN Health Center from another practice.

As required by the Health Insurance Portability and Accountability Act of 1996(HIPPA). This practice may not

disclose your individually identifiable health information without your authorization except as provided in our

Notice of Privacy Practices. Your completion of this form means that you are giving permission for the uses and

disclosure described below.

Please review and complete this form carefully. It maybe invalid if not fully

completed. You may wish to ask the person or entity your want to receive your information to complete the sections

detailing the information to be released and purposes for the disclosure.

I hereby authorize

Phone

Fax

To release health information of the patient named below:

Name ____________________________ Date of Birth

SS# _____________________

Dates of service to release:

Entire medical record

Exclusions (Please initial): Drug/Alcohol

Mental Health/Psychiatric ___ STD ___ HIV/AIDS ___

Other ___ Description of other exclusions _________________________________________________

Reason for release: __________________________________________________________________

Please send records to: OB/GYN HEALTH CENTER

Phone: 386-258-0123

769 N. Clyde Morris Blvd

Fax:

386-258-6464

Daytona Beach, FL 32114

This Authorization is effective this date _____ through _____ (Dates must be specified)

Date:

Signature:

Print name:

Please Check: I am the ___ Patient

___ Guardian ___ Patient Representative

*If this form was completed by someone other than the patient, please print name and address below*.

Name:

Address

I understand that I have the right to receive a copy of this authorization

medrectous

Medical Records Request Form