Medical Records Release Form


1005 Mar Walt Dr.
Patient ID # _____________
Fort Walton Beach, FL 32547
Internal Use Only:
Telephone #: _______________
Routine: _____________
Fax #: ____________________
Stat: _____________
Medical Records Release Form
I authorize White-Wilson Medical Center to release or obtain confidential health information about me by releasing/requesting a copy
of my medical records, or a summary or narrative of my personal health information to/from the physician/person/facility/entity below.
Patient Name: _______________________________ Date of Birth: _______________ Telephone #: __________________
Special Releases:
I consent to the release of any positive or negative test results for AIDS or HIV infection, antibodies to AIDS or infection with any
other causative agent of AIDS with the remainder of my medical records.
Initials: ________________ Date: _________________________
I consent to the release of any records related to treatment for Behavioral Health or Substance Abuse with the remainder of my records.
Initials: ________________ Date: __________________________
The information you may release, subject to my signature on this release form, is as follows:
___ Complete Records
___ History and Physical ____ Care Plan
___ Immunizations
___ Lab Reports
___ Radiology Reports
____ Pathology Reports ___ Treatment Record
___ Operative Reports
___ Hospital Reports
____ Medication Record
___ Other (please specify) ____________________________________________________________
____ 1 Year
_____ 2 Years
____ Entire Record
Release my protected health information to:
Request my protected health records from:
Name: _______________________________
Name: ______________________________
Address: _____________________________
Address: _____ _______________________
City/State/Zip Code: ___________________
City/State/Zip: ________________________
____ Mail
____ Pick Up
____ Fax
____ Other (Specify): _______________
Phone #: ___________ Fax #: (Doctor’s Only) ____________ Phone #: _______________Fax #: (Doctor’s Only) ____________
I understand that:
1. I may refuse to sign this authorization as it is strictly voluntary, however, records cannot be released without authorization.
2. My treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization.
3. I may revoke this authorization at any time in writing. Prior releases of information remain covered under the authorization
in place at the time they were released.
4. If records are released to an individual other than a health care provider or health plan that information may no longer be
protected by federal privacy regulations.
5. I understand that there may be a fee for records released to an individual other than a health care provider.
6. I may request a copy of this form after it is signed and dated.
Patient’s Signature: _____________________________________________ Date: ___________
(Required for all patients 18 years and older)
Signature of Parent/Legal Guardian: _______________________________ Date: ___________
(Required for all patients under 18 years of age unless otherwise allowed by law. If legal guardian is signing, appropriate documen-
tation must accompany this form)
Records will be provided to another health care provider at no cost. There is a copy fee for release of medical records for the patient's personal use.
Prepayment is required before records can be released.


00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal