Medical Records Authorization Form printable pdf download

Medical Records Authorization Form

To: _____________________________________

_____________________________________

You are hereby authorized, and hereby requested, to furnish Long Island Radiation Therapy copies

of Medical Records pertaining to:

Patient’s Name:____________________________________________

Date of Birth:____________________________________________

Social Security #:____________________________________________

This authorization and request is valid from the date hereof until ___________________________ .

I understand that the information that I hereby authorize to be disclosed pursuant to this form may

be subject to re-disclosure under certain circumstances.

I understand that I may revoke this authorization at any time by giving written notice of revocation

to the person or entity first-named above. Revocation of this authorization will not affect any action

taken in reliance on this authorization before written notice of revocation is received.

I understand that neither treatment nor payment enrollment nor eligibility for benefits is conditioned

upon the execution of this authorization and request.

Dated:________________________________

______________________________________

___________________________________

Signature of Patient or Personal Representative

Name of Patient or Personal Representative

_________________________________________

Description of Personal Representative’s Authority

Medical Records Authorization Form