Medical Records Release Request Form
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1Ben L. Nguyen, M.D.
Jae Y. Lim, M.D.
Medical Records Release Request Form
Please allow up to 7 days for processing
Today’s Date: __________________
Patient’s Name: ______________________________________________
Date of Birth: __________________
Daytime Phone Number: ______________________________________
□
I would like a copy of my medical records:
□ Pick-up in the office (Our office will contact you once your record is ready)
□ Fax: _____________________________________
Attn: __________________________________
□ Mail: Address:_______________________
____________________________________________
City: _________________________________ State: _______________ Zip: ____________________
□
I hereby request my medical records be released and submitted TO:
Physician or Institution’s Name(s)
Address
Phone & Fax Number
Information to be released:
□
□
□
Office Notes
Operative Reports
Pathology Reports
□
□
□
Radiology Reports
Procedure Notes
Other: _______________________
I, the undersigned, request and authorize Atlantic Brain & Spine to release the medical information to mentioned
above. I understand that if the person or agency that receives my information is not a healthcare provider or health
plan covered by the HIPAA privacy regulations, the information described above may be re-disclosed and is no
longer protected by these regulations.
____________________________________________
_________________________
Patient or Authorized Representative Signature
Date
*This authorization will expire in one year from the date signed
Mail or Fax completed form to:
Atlantic Brain & Spine
8501 Arlington Blvd. Suite #330
Fairfax, VA 22031
Fax: (703) 876-4276
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