Centralized Medical Records
1233 E. Second St., Casper, WY 82601
Phone: 307‐577‐2089 Fax: 307‐233‐8133
Records are requested from:
SAGE PRIMARY CARE
CASPER PULMONARY
WYOMING BRAIN & SPINE
WYOMING NEPHROLOGY
WEIGHT MANAGEMENT
WYOMING ENDOCRINE &DIABETES
MESA PRIMARY CLINIC
ADVANTAGE ORTHOPEDICS
IMMEDIATE CARE
MEDICAL RECORDS REQUEST
*required fields
*Patient Name: _________________________________________________________________________________
*Telephone #: __________________________________________________________________________________
*Date of Birth: ___________________________________ Social Security Number:___________________________________
RELEASE FROM
RELEASE TO
*Name:
*Name:
*Address:
*Address:
*Phone #:
*Phone #:
Purpose for disclosure:__________________________________________________________________________
Date(s) of service to be disclosed:_________________________________________________________________
Information to be disclosed
___ Entire Medical Record
___ Clinic notes/History & Physical ___ Discharge summary
___ Procedure Reports
___ Laboratory/Pathology Reports
___ Radiology Reports/Films
___ Consultation Reports
Other:______________________________________________________
*Specific Authorization to Disclose Sensitive Records*
I understand that this authorization is to include disclosure of (please initial):
___ Alcohol &/or Drug Abuse Records
___ Psychiatric Records
___ Sexually Transmitted Disease Information ___ HIV/AIDs Information
This information is disclosed from records whose confidentiality is protected by federal law. Federal Regulations (42 CFR Part 2) prohibits you from
making any further disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitted
by such regulations. A general authorization is NOT sufficient for this purpose.
I understand that I may revoke this authorization, in writing, at any time except to the extent that Wyoming Health Medical
Group, LLC has already relied on this authorization.
I understand that I may revoke this authorization by sending or faxing a written notice to the Chief Privacy Officer, 1233
East Second Street, Casper, WY 82601 or fax (307)233‐8133, stating my intent to revoke this authorization.
Unless otherwise revoked, I understand that the specific date or event upon which the authorization expires
is_________________or one year.
I understand that Wyoming Medical Center/WHMG may not condition treatment, payment, enrollment or eligibility for
benefits on the completion of this authorization.
I understand that the information being disclosed may be subject to re‐disclosure by the recipient and may no longer be
protected by the Federal Privacy Law, if the recipient is not a “covered entity”.
I understand that the information being disclosed may contain information from non‐WMC providers and that information
may not be complete.
SIGNATURE: ____________________________________________ DATE: _____________________________
Printed Name of Legal Representative:___________________________________________________________
Legal Representative’s Authority to Act for Patient:__________________________________________________
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐DISPOSITION OF RELEASE ‐‐‐‐‐ OFFICE USE ONLY ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Faxed: __________ Mailed:__________ Patient pick‐up:__________ Intake Staff Initials __________
11/2015